Quackenbush, Mary It
518 273 1029 p.1
4 -.)6.3
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First „Middle Last Sex -
14 ram aV?kG1e-E Nay s 1-1- I-
Date of Death Age If Veteran of U.S. Armed Forces,
1c71124 o t1 r 17 War or Dates
Place of Death j°°i i I q._,i•° ospital, Institution or '`_
City,Town or Village SCH '•°l =:xa'-^" ! x treet Address e 0-1 5 40Sv lT(1r L.
cc Manner of Death Natural Cause D Accident Homicide Suicide fl Undetermined Pending
Circumstances Investigation
Ii# Medical Certifier Name Title
Address
Death Certificate Filed _ ': -I District Number JI I�j Register Number
City, Town or Village. �.�
❑Burial - I Date Cemetery or Crematory
> : ❑Entombment (O i to�z c� ti� f I+J e V t IN i� b 1�t U r!
Address
4115Cremation 40 i.Itkr AveFAut , PC x 115-I sc. tC1-G.q,i , t3 -1 E Z- oc-‘
:.: Date Place Removed
Removal and/or Held
2 and/or Address
t Hold
U]
1.0 Date Point of
fh fl Transportation . Shipment
6 by Common Destination
Carrier
in
n Disinterment Date Cemetery Address
::' Reinterment Date Cemetery Address
Mi Permit Issued to f Registration Number
Name of Funeral Home l tl Q(PP it)Uf2A( Phitif
Address
..:'.1!.:' A 1Mlif N) ST ii U PiOl`i Cilit5 ri )1,31
Name of Funeral Firm Making Disposition or to Whom
i i Remains are Shipped, If Other than Above
2 Address
LC
1LI
II Permission is hereby granted to dispose of the human re sgescn dove as indicated.
Date Issued Registrar of Vital Statistics ;:;, .:''.i ti ct !;'j -
x r,.. (signature)
District Number " 'Place
#- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z nf".1,,V....... /
al Date of Disposition /0/lb1'Y t,�Place of Disposition �,•a.jo'h�
2 (address)
W
03
(section) A ;lot number) (grave number)
Q Name of Sexton or Person in Charge of Premises L ^e,� j4A4
(p! ase pert)//� �o
• Si 9 nature Title f'1 '�1`r�-
(over)
DOH-1555 (02/2004)