Witiak, Mary 20
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
i\AC r- ' 11 1(\dIiil kr— Rilla lc
Date of Death Age If Veteran of U.S. Armed Forces,
3-Q i3-- ( 1 Cj G' War or Dates J/i
1.- Place of Death Hospital, Institution or c
�(Cit-OTown or Village��P,,,a-(-o & Si3r-i��_� Street Address -p r'y)< of fr c Good Shp/W
0 Manner of Death Natural Cause El Accident ❑Homicide ❑Suicide ri❑Undetermined ending
LU Circumstances Investigation
W Medical Certifier;,, Name Title
0 Ai nee, McMask, ACN/�
Address
1 Ihen fl ,.
Death Certificate Filed District Number Register N9 nber
it Town or Village j'ccf�J& c i rice; -ic 1� ( ( . #3
DBurial Date C etery or Cremator
Entombment 0 3 --` `i -1 1 V i r)e V i e to C,(`Pi"Y1lti'I`c rl
Address cr.\
'V]Cremation ULU.nS jj krz fvt\
Date J Place Removed
Z ❑Removal and/or Held
2 and/or Address
F_- Hold
in
O Date Point of
oi ❑Transportation Shipment
C by Common Destination
Carrier
Q Disinterment Date Cemetery Address
2 I:Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home l3 rt L;�f -{ .i ;r�;,i -40 r( \i'\c_ boat '
Address
4 C' h Lk rc in St lit Ki Lckze.;iv ki y Il s
Name of Funeral Firm Making Disposition or to Whom
_Remains are Shipped, If Other than Above
,', Address
it
ICJ
fl Permission is h reby :anted to dispose of the human remains described above as indicated.
Date Issued �,� '� Registrar of Vital StatisticsL ti _ 1J
(signature)
District Number (-1 svf Place SA,ffi-rtio... '�
l
':_ I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI Date of Disposition 31.311r) Place of Disposition ps VR /riThKtol'Iun.,
(address)
Itil
VI
CC (section) /i (lot number)
,1 (grave number)
• Name of Sexton or Person in Charge of Premises l �jrsr^ S b��l�4T
z /�' (Please print)
• Signature v� Title (RErAfiit
�
(over)
DOH-1555 (02/2004)