Beaupre, Mary if r # 6°it
NEW YORK STATE DEPARTMENT OF HEALTH Burial m Transit Permit
Vital Records Section
Name First Middle Last Sex
Mari I.00 -Se t3e..av pt� fF
Date of Death l 0, 3i g Age$Z I If Veteran of U.S. Armed Forces,
,:.:::„,;
I1 War or Dates
Pace of Death(City)TownHo ;_ tutton or
or Village C lens Street Addr- - Z� l e. 'S .
la
CI Manner of Death Natural Cause El Accident f Homicide ❑Suicide Undetermined n Pending
Circumstances Investigation
tij Medical Certifier Namj � Title
CI ' Nn Coveav f i La C l
Address
I 1 ons3ctti. aitti,r ,6 lore Fes, ►.)Li 11
Death Certificate Filed Faits I District Number Register N mber
:is ab Town or Village C`€n S i �7'�0 I 1�8't'
El Burial I Date Cemetery or Crematory
1�'It�'ZO��' eR,Y1e 11i et4 ete Svc--I
❑Entombment Address
:t Cremation cc * - \ rck Gep1,j�,� , N,� k Z$0 q
'' I Date j Place RemoJed
CRemoval ; and/or Held
and/or I Address
Ch
Hold l
.0 Date Point of
fE Transportation Shipment
a by Common Destination
Carrier
['Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home 1 .1e'}C= `,1L;z l k\0�1 t- 0`
C.ti l : L
Address
Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
• Address
CC
111
- Permission is hereby granted to dispose of the human emains d cribed a ve as Indic- ed.
Date Issued/0 /0 p/ Registrar of Vital Statistics ; _./,_
(sign re)
>_ District Number/ Place ��
I certify that the remains of the decedent identified above we disposed of in accordanA with this permit on:
til Date of Disposition Join is Place of Disposition "E V (, ,6,
2 (address)
t
I (section) (I (lot numb�} (grave number)
� Name of Sexton or Person in Charge of Premises �lisi ( J e4...40
24 (p ase print)
w Signature !-f TitleK 'IT1_
(over)
DOH-1555 (02/2004)