Miner-Cooney, Ruth NEW YORK STATE DEPARTMENT OF HEAD . R .!-� till
Vital Records Section r Burial - Transit Permit
Name First R,4-i, L. Middle An Last Sex F
Date of De th Age If Veteran of U.S, Armed Force
/V a , a of 7 S," War or Dates
} Place of Death . Hospital, Institution or
lZ Cit own er Village (. (`.\4,- k Street Address 17 H.I'i,c 12,A
2 Man - o Death i5 Natural Cause 0 Accident 0 Homicide 0 Suicide 0 Undetermined — Pending
Circumstances -"Investigation
W Medical Certifier Na7 Title
CI 5
Addr ss
Death ificate Filed District NumberRegister Number
City, awn r Village C_9' ` S3.-3 1
Date Cemetery or Crematory
nBurial 5-73J /aot7 ,;,*v,.c..., .zM4- %�/
n Address r."‘
LYi Cremation
.A.ecnyj✓r N�� / ,r✓(
Date �' Place Removed
ZO Removal and/or Held
H and/or Address
- Hold •
O Date Point of
N —Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address.
E
Reinterment Date Cemetery Address }
Permit Issued to Registration Number
Name of Funeral HomeG em s,,,,.,rc_ Av.t )-1,,,..,, O 0 `7-'r1"
.;:;,.ii Address
7 MOT /1'b),z.
car Al..,�..� C o r
, 1 ,
Name of Funeral Firm Making Disposition or to Whom
�" Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human r: - = • _scribed ov: • •gated.
Date Issued S/3° //T Registrar of Vital Statistics Age
g
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District Number LfS-53 Place �d i • L- N
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
wDate of Disposition 6, / I f 1)Place of Disposition 'girt 4Vtc.../ tl;.•ngor_
.• (address)
LU
V)
CC (section) �Ipt nu ber) (grave number)
Q.Name of Sexton or Person in Charge of Premises �'�r r' c 1I
w
4. (please print)
Signature Title 1teE ril►WO.
DOH-1555 (10/89) p..1 of 2 VS-61