Fink, MaryAnn r It it 01
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First- Middle Last Sex
ili CI CI) k''1 4 Rynct ie,
111 5- n +-I
Date f �J Dea Age If Veteran o U.S.Armed Forces,
I War or Dates n
'`` Place 1-a h Hospital, Institution or
City . ,own Dr Village 1 l)d 0 4 112,16L. Ru .chc StreetAddress ) "1 'cod-- lin
Mann- • •eath Z Natural Cause Accident Homicide Suicide Undetermined Pending
i Circumstances Investigation
tg Medical Certifier Name Title
12 I.
tcQr .,��nes p
A
1 yr)LeunAd restscia, Air
• Death Certificate Filed // District Number Register Number
City, Town or Village / f)C/j!)I) La kt 0-O s 9
❑BUCIaI Date go AO/ I-,ytery o�C Cremafpry_ r-t i n
<>❑Entombment / 1 V 1 ) �!`no
AcItis .
;r remation ( bru Ny
Date ..J Place Removed
f❑Removal and/or Held
and/or Address
I" Hold
Date Point of
0 Transportation Shipment
.
„„ by Common Destination
Carrier
[i Disinterment Date Cemetery Address
❑.Renterment Date Cemetery Address
Permit Issued to 1 �Reg tration Number
Name of Funeral Home J\JIkx' )uyy v 1 Q, �jig 9
Address (o .-7 IS & -30 )) 1(1I i 1 !2- 4�Name of Funeral Firm MDisposition.or to Whom .
i Remains are Shipped, If Other than Above
Address
s
ILI
/27 Permission is h eb granted to dispose of the human e ains describe above as indicated.
Date Issued Registrar of Vital Statistics [th, a
(signature)
District Number 2 O' 3 Place j ), GLAA
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
E. Date of Disposition 9 Place of Disposition P hill� P �nD U� �ra..�o�-
(address)
(section) (lot nu.4
ber) (grave number)
.. Name of Sexton or Person in Charge of Premises
z (please print
::' Signature �1 Title rfa''ti',P—
(over)
DOH-1555 (02/2004)