Cunningham, Mary NEW YORK STATE DEPARTMENT OF HEALTH k j'''t
Vital Records Section Burial - Transit Permit
•-.-, Name First Middle /) Last
447
Death i
FY'
,..i Date of Age n,A IfVetenxi of•U.S.Armed Forces,
e-A? -- 1471 War or Dates
-.4.
ffrA Place of Death Hospital, Institution or ,
City,Tom or Wage (1211-Th ili ' Street Address H-4 Mt_ c,),% 7-71 6:040SA,14A4P-0
a Manner of Death GICklatural Cause 0 Accident 0 Homicide 0 Sidcide 0 Undetermined .0 Pending
Circumstances Investigation
Medical Certifier Name
- -. atiaib 64,0 Title
1 -- .
1Address (7"----7:9-4r-S A--)-1 k.1.,cf-:0 /
AR Death.Certificate Filed , District Number i / /-} Register number
14, City,Town or Vdiase . 011-17-46-/L-J Ai -L-)Cgti (..- I
..0. C-. .wy or Crematory
v ElBurial - Date C-- /
I.g'sti rl AddresoOsA42-A/C1-- P40-2_13,te.x3 0,21-44-i4-7-b-ktcLti ,
uEntanimeid #,
c,t_
iie, atN-24.6;'&A A, ± /-) /-216 y
lLiieremation e--2/ 62LLAt-
p: Date 0 Place Removed
• 0 Removal Address
Hold
[3 Transportation Date Point of
by Common Destination and/or Held
IShipment
4i Carrier
...14 •
,Ve u:-.t r—i D ment Date Cemetery Address
mi isinter
Li,Remterment. Date Cemetery Address
---4%.*-
f :? Permit Issued to 4 7 I Registration Number1... Name of Funeral Home
. " J..0(9----7/. 1 iitos- 4
,-...,: Address
/
..-*L. Name of Funeral Firm Making Disposition or to Whom
,...,:.
s' Remains are Shipped, If Other than Above
Address
.., Permission is hereby granted to dispose of the human rem ns described ye as indicated.
......
A Date issued sitp/.201 rRegistrar of Vital Statistics ciA ' Pr2/AAA,‘_
ort .
(sigoototoi
It District Number 461„q Place --Fwn 0-p a), 1, )-y)
,45
'1 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition q I 4 iK Place of Disposition
1
' eott./ ii414,..4oi
(address)
Oot 7r (grave number)
ol S
—) 147
I Name of Sexton or Person in Charge of Premises ("dim) 13,Tht) J.
Okmise
4_
Signature
EA , Title larrotn,
do
(over)
•
DOH-1555(02/2004)