Boatelle, Marion NEW YORK STATE DEPARTMENT OF HEALTH , E
Vital Records Section A Burial - Transit Permit
Name First � Mi1cJ,dle �o� �s�Le._ Sex �
Date of De th i Age If Veteran of U.S. Armed Forces,
6, /t7/Q0Icit I I War or Dates
Place of Death Hospital, Institution or
WCi gown or Village L 6�.4,� Street Address
anne ,r of Death RVatural Cauee D Accident 0 Homicide ❑Suicide D Undetermined pi Pending
la Circumstances Investigation
W Medical Certifier Nam Title
A;'L. /V)et LCr, rk l
Address / ,J A A
.A/ H /-, N w S,Lc,-�t, Aye_ is,,,,,,_ AJ r l a a,)cl
D. h Certificate Filed District Numbe! Register Number
ity, own or Village AL ��/ 010,
❑Burial Date o Cemetery or Cre tory 6
ilz-r-
M❑Entombment Address
[cremation 7A.e_e,5 .5,--1 tliz,.., 7;r.
Date (/ / Place Removed
Z Removal and/or Held
d❑and/or
Address
Hold
0 Date Point of
t
Transportation Shipment
a by Common Destination
Carrier
m ElDisinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to „�- Registration Number
Name of Funeral Home .,.,,rt 1 k,,,,, .6. Ft/4^e' 1..` C�a t`te
Address Ave, /�
7 $ Cr t'1 A 1 -,pi': ' 13 rYZ
Name of Funeral Firm Making Disposition or to Whom
14 Remains are Shipped, If Other than Above
a Address
ILI
Permission is 7eby/ranted to dispose of the human remanr d ribe v„e as indicated.
Date Issued 67Registrar of Vital Statistics
(signature)
District Number O1 v t Place 9Z_At6 j di
I certify that the remains of the decedent identified above a disposed of in accordance with this permit on:
p io�i9�14 p '�i«.��... (s4 " .
Lil Date of Disposition Place of Disposition c
W (address)
if)
CC (section) (lot number) C (grave number)
OName of Sexton or Person in Charge of Premises �n�tp1.� J a-�-{
Z ( lease print)
iii
Signature L1 e Title Alit.,
(over)
DOH-1555 (02/2004)