Colson, Mabel NEW YORK STATE DEPARTMENT OF HEALTI4 1 A ZZ
Vital Records Section Burial - Transit Permit
f Name First Middle Last
►I . .- Co]sonPE3('TY / -
' Date of Beat Age If Veteran of U.S. Armed Forces,
--�3'�t 1g .-7 War or Dates no
Place of Death Unv Creel Hospital, Institution or
-: City, Town or Village �� /-1,ry(5 9 Street Address �vx y-r t 3 a Pd
Manner of Death w Natural Cause ❑Accident ❑Homicide ❑Suicide ❑ Undetermined) El❑Pending
Circumstances Investigation
Medical Certifie NamA Title
u.1 ( chmcc.rn a 0
Acldrgss
1./UCLf---rcAsbii a
it Death Certificate Filed District N tuber Registar Number
City, Town or Village i') l Pree-.0 /
Date 1 q-e1etery or Cremator
,, ❑Burial 1 —i—20 I g _ f j YAP_ r-.�tc� l 'i Ycti�`)
❑Entombment Address
Cremation Q ,e-nsbu iczj
Date Place Re(noved
❑Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
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❑Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
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Permit Issued to / Registration Number
Name of Funeral Home }� '}-ems ,{vo .y, z ( E-cni ? / y)c dal//
1, Address
4" 4;?4- A z,k La ze r-n.e i /2;'
AT Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
- Permission is h reby granted to dispose of the hu re ins described abov indicated.
t. : Date Issued I `/ 13 Registrar of Vital Statist' ,��A k j . <'Z
(signature)
fio
District Number 565g Place l 0 GJ n 6 dreit.
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
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Date of Disposition I/rII$ Place of Disposition e„a,).,. Lcid
-, (address)
9
,--
(section) Apot number) (grave number)
Name of Sexton or Person in Charge of Pre .ses ,„ S.r~'�
(pleeise print)
,,
Signature Title Ilkollnr
(over)
DOH-1555 (02/2004)