Mosher, Doris NEW YORK STATE DEPARTMENT OF HEALTH -.
Vital Records Section Burial - Transit Permit
iiie Name first Middle Last Sex
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o21s S . a (LQ
iii Date of Death Age If Veteran of U.S. Armed Forces, a_„__
D a LQ - o;1.0 I7 (.o War or Dates
Place of Death Hospital, Institution or
City, Town or Village Lakz } \r- n- Street Address ! x L4tvc Ave 4---
NManner of Death air Natural Cause ❑Accident uHomicide ❑Suicide ri Undetermined ri Pending
til Circumstances Investigation
twi Medical Certifier Name Title
& tics_ &-ii et
Address
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/ rrtnS6 �0 N /
Mi De e • . ate Filed District Number Register Number
Ci , Town o Village L 4 Yf� L K Zc-t� 5 G 5 G eC
Date Cemetery or Crematory
El Burial J G'/ a7 /aJ,7 :��V:c� - t
Address c U
Cremation C)iAetAst)v r Ajt L.0 ���✓l
gDate D-) Place Removed
0 Removal and/or Held
rf and/or Address
aHold
E Date Point of
ti 0 Transportation Shipment
0 by Common Destination
Carrier
Disinterment Date Cemetery Address: El
Reinterment Date Cemetery Address
Permit Issued to Registration Number
iiiiiiiii 7) /,qC/97Jr Name of Funeral Home i re iti,„p/-0 / / " "ram-Q /U 9 /U
i iiii 2 Address
NaName of Funeral Firm Making Disposition or o Whom
' Remains are Shipped, If Other than Above
Ng Address
::.>. Permission is hereby granted to dispose of the human sins des,- ibed a;of as indicate .
n
I Date Issued /a/, 7 / ? Registrar of Vital Statistics ,,t I-A �.
/ J (si ature)
District Number J_ L
65 Place a-Ae ��`-a ZQ-' ! y /a2re/6
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Fill p
Date of Disposition /0/3'In Place of Disposition 'l i.rtLd C a i✓
a (address)
LLI
U3
! (section) Apt n'arnber) (grave number)
Name of Sexton or Person in Charge of Pr ises (ram SN /
g (please print) Y
kl Signature d
Title itt4/MK.
(over)
DOH-1555 (9/98)