Parker, Marion NEW YORK STATE DEPARTMENT OF HEALTH' .
4' en
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Mar t o rl P Par Kea-- Fent lc
Date of Death A. e I If\i gran of U.S. A rmed Forces,
l i -1_9_-_a4DA 1 1 War or Dates o
H Place of Death Hospital, Institution or
_
City, Town or Village d 1el� Str et Address 39 Acir rcr1CIack iU
p Manner of Death®Natural Cau e Accident [J Homicide El Suicide ri❑Undetermined ❑Pending
W Circumstances Investigation
W Medical Certifier Name Title
n Mar K - o-('FrAan M.D
Addre
kil 5 ra u s
Deategificate Filed' I�, District Number Register Number
ow City, Tn tK,(
r Village <1 I CA( �f55 g 1 LI
❑Burial Date ( emetery or Crem, dory
❑Entombment I e-ao -do i 7 1 ne vI a L /emaTtO
Address
.;'Cremation QueehsbL(
Date Place Removed
Z n Removal and/or Held
9 and/or Address�
In
Hold
0 Date Point of
CL ❑Transportation Shipment
G by Common Destination
Carrier
❑Disinterment Date I Cemetery Address
Renterment Date Cemetery Address
Permit Issued to Re istration Number
: Name of Funeral Home�3r�IJe `r ule_roJ 4/W 1 /nc Opal(
Address
ULLaik St L-oiKe, Luz.{-r-r� AN/ 'Watt
; Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
tr
'
4' Permission is hereby granted to dispose of the human remains described above as indicated.
c /
,U
Date Issued 1, ZDI fl Registrar of Vital Statistics ;L,�4r (_..(., ,4„,.
(signature)
District Number
ass Place--Lowy) Q) _l_iaci
' I certify that the remains of the decedent identified above were dis sed of in accordance with this permit on:
,p� ' I
fa Date of Disposition Ili it Ill Place of Disposition i l la", (-+ —.
a (address)
Ili
(section) ff (lot number (grave number)
pName of Sexton or Person in Charge of Premises C'" ' L ,�1 v tt
z please print)
7
l Signature Title liGmrtiW-
(over)
DOH-1555 (02/2004)