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Fisher, Mary Ann r \ 41 346 NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name��rst Middle Last Sex f) Fi,5 6e7" F422 Date De th Age If Veteran of U.S.Armed Forces, 5/3 l? 7 R War or Dates Ala F- Place of ath Hospital, Institution or I W City, if- Rd Town or Village riel i cu l 1. a Street Address / ) d_c p I pManner of Death RI NaturalCause Accident Homicide Suicide Undetermined Pending Circumstances Investigation W Medical Certifier Name Title o Or/ lr)pher `Jacks0h R PA Address Ind! col lake NY Death Certificate Filed District Number Register Number t City, Town or Village fd Ca h Led<f2 _ -V)S3 '5' ❑Burial Date`� I etery or/Crematoj 0 Entombment / (v 1 / s l r Y t P.t,D l t�-1lYl R 70 Y1 Address 'Cremation GU Q..Q ti) bl Ny Date ce Remo ed Z Removal and/or Held C❑and/or Address I= Hold U) 0 Date Point of NQ Transportation Shipment G by Common Destination Carrier 0 Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to n p Registration G Number Name of Funeral Home �vl i l 1e f'' 1-4-ant � g /1 ( / Address £ ')5 5 i J__ v 3 0 1 r t 1 a i L&. / /tY) z Name of Funeral Firm Making Disposition or to Whom I— Remains are Shipped, If Other than Above a Address QG W a Permission is h by granted to dispose of the human remains described above as indica Date Issued 5 G Registrar of Vital Statistics . (signature) District Number a-o 5-3 Place ) id( Q`k1 LJ_ , ts\A/ I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z © � WW Date of Disposition S/� hg Place of Disposition t'u i1„„ l r�1� W (address) (/) (g (section) /, (lot number (grave number) pName of Sexton or Person in Charge f Premises '2.. 3*wtb' W (phase print) Signature loll Gam- Title ( EfiN (over) DOH-1555(02/2004)