Magee, Edith r ! # - g
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Per It
Vital Records Section
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': Name First M dle Last Sex �—
�� PAC?
.....
< Date of each Age If Veteran of U.S.Armed orces,
— 2 — War or Dates
04 Place of Death Hospital, Institution or City, Town or Village 0 0 rt/ \ Street Address 51 8 7 ` jJ
O Manner of Death Q Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
ILI Circumstances Investigation
tu Medical Certifier [lame Title
AL ;s Al , Mot,Liik fNP
Address 44 c�
to f �.�Pc� „�cc. syJ N l�K®
Death Certificate Filed r C / District Num r Register Number
'` Cityown Village l�0 r; '-"-'r.\ Lf —� at
Date Cemetery or Crematory
>: ❑Burial CV I l/aJ/y- P6
Address y
:' II Cremation ue, ,� ,,,, �J I
Date Place Removed
0❑Removal and/or Held
-- and/or Address
FAHold
Q Date Point of
riS❑Transportation Shipment
C by Common Destination
Carrier
Date Cemetery Address
❑Disinterment•
❑Reinterment Date Cemetery Address
Permit Issued to " \ Registration Number
Name of Funeral HomeG"A.,,,,.)n- �Ac sk ( (49 ..1 4--)" ` `Sr
Ng Address 1
Name of Funeral Firm Making Disposition or to Whom /
..,. Remains are Shipped, If Other than Above
Address
Permission is, ere y granted to dispose of the human r, •escribe ab indicated.
Issued3s Date 7 Registrar of Vital Statistics , , y,
iti ''J') signa re)
iiii District Number di/633 Place (ik4-t'#4
I certify that the remains of the decedent identified above re disposed of in accordance with this permit on:
f /
• Date of Disposition 611(r(Ii i Place of Disposition gu 4 lta or,-
M. (address)
LU
N
CC (section) (lot mper) (grave number)
GName of Sexton or Person in Charge of Premises trt�ti1r St.,ntv
gb 4 (please print)
94 Signature Title &E 4i
(over)
DOH-1555 (9/98)