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Barrett, Mary
NEW YORK STATE DEPARTMENT OF HEALTH - • Iw fl 16R Vital Records Section Burial - Transit Permit -2 Name First 11/Pky Middle Last S 641-,eazT7` iht‘C r Date of Death Abe if Veteran of.U.S.Armed Forces, /�/ �/J- r.-- War or Dates Place of Death Hospital, Institution or .7r.i. City,Town or Village tI -N.43 - Street Address/f 7 C/itS ccr-,1 © -k ,'t 1 r Manner of Death ri Natural Cause 0 Accident 0 Homicide 0 Suicide u _Undetermined El Pending Circumstances Investigation Medical Certifier Name s k-j 0 56,.E Title Death Certificate Filed _ District Number )Register Number ; ,Town or (!•. l fL x2:I3�c 'y s j OBuriat Date' /2f � or Crematory 14 QF ant>mem Address issL.v c.E-L 3 a oe lei'tl g lact BCremation 0 / u.fZl i�. ,.moo se . 6ri 5 ,iJ /M V f. Date Place Removed ._❑Removal and/or Held ii for Address 1 Hold *; Date Point of .. Q sq. Transportation Shipment r.-, by Common Destination M. Carrier • El Disinterment Date Cemetery Address liReinternent Date Cemetery Address 1 guPermit Issued to k. �... / Registration Number Name of Funeral Home e' AA LCW' C�v�N� I �5'— Address�A l4Jd9-.2kiu' C._.t. CcCS AJ i / / Name of Funeral Firm Making Disposition or to Whom l Remains are Shipped, If Other than Above { Address !Yi ;If, Permission is hereby granted to dispose of the human sins described above as indicated. we Date lssuedia 1 K I�U\ Registrar of Vital Statistics CA-_,---. G}. 03 —� O District Numt --) Place c______ C a„ f)....._.1..., k': I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: t Date of Disposition 12 I(0 lit Place of Disposition * ,,,V,,,, Autos (address) (section) nPotnumbedc (grave number) Name Sexton or Person in Charge of Premises t( ttirpiti JO•val Y'.,.5 signature Title Pang On g (over) DOH-1555(02/2004)