McPeterson, Isabel NEW YORK STATE DEPARTMENT OF HEALTH � � Burial - Transit Permit
Vital Records Section
Name First Middle I est,- SeX
-Ls b-z -- A c //r-lti S r 1---e r7 at_Cr
I_
:i: Date of Death �J Ale e I. Veteran of U.S. Armed Forces,
2- 1 CI War or Dates ,J1/
Place ath ' Hos - titution or
City, own -Village Q U c 4vyc c. treet Address t
/ t, � )c_,i_a JS'/c/ IG2.0
ti Manner of Death caNatural Cause 0 Acc ent [i Homicide Ej Suicide LEl_t Undetermined n Pending
ILICircumstances Investigation
Lu Medical Certifier Name �ae� S�,�. 1Title
, om D
Address
It:.1 4 ROAD aAENJP4 11 it4 1786Y
:: Deat rtificate Filed District Number Register Number
City Town)r Village >)u.a.-ws8 U S(9S
Date 7 Cemeteryo Crematory
❑Burial , /1
0-Entombment
/� l / / 5-- t//(�-
Address
Cremation
Date Place Removed
0❑Removal and/or Held
— and/or I Address
It Hold
0 Date Point of
E Transportation Shipment
5 by Common Destination
Carrier
: : [l Disinterment I Date Cemetery Address
Reinterment Date I
Cemetery Address
Permit Issued to Registration Number
< Name of Funeral Home r \(T �;1L;r \ t•'1Dc1 t. C 1 l 0
Address
\r k--c,.(ctl t.\V- L-. C \L 1 / 1LNk czeo c`l
vi✓C:::1S
`< Name of Funeral Firm Making Disposition or to Whom
I . Remains are Shipped, If Other than Above
Address
M
113
Permission is hereby granted to dispose of the human re ains described above as indicated.
Date Issued—)'31 % Registrar of Vital Statistics qrL.4--`
(signature)
District Numbe --) Place ) O cA_-6-., c"r ( Lr_
I
I certify that the remains of the decedent identified above were disposed of in acco anc with this permit on:
lit Date of Disposition 81 Z 11T Place of Disposition P,SL i l�q,-.
(address)
la
1 (section) (lot nyrbep C (grave number)
Ct
Name of Sexton or Person in Charge of P emises I1ri to J1 Ut
Z (please pn )
. Signature A Title WW1 1>A
(over)
DOH-1555 (02/2004)