McNally, Leo NEW YORK STATE DEPARTMENT OF HEALTH
f ' # 611
Vital Records Section Burial - Transit Permit
Name First mc�,u A// Last Sep?
Date of Death r Age If Vegan of U.S. Armed F rcess C/
Q�f _ /3 — �'/ 7 Ers' War or Dates /9v,j.dir- /V,575-
Place of Death --�- / Hospital, Institution or
Z City, Town or Village rld 41uS.6;,l^ Street Address/Vito/4,4,jc j a.) .-(°�,, h/e,o(711 G�� i e .-
Manner of Death yr Natural Cause [Accident 0 Homicide ❑Suicide ❑Undetermined ❑Pending
Ili r" Circumstances Investigation
tu Medical Certifier Name f Title
s^
TAnte3 F AJNdSOv !'o
Address
Ira S K 6 oee1 Ra - 000-t, et-e-K N y j a8.S3
Death Certificate Filed ` District Number Register Number
piipipi City, Town or Village �jµ.6,bv —��j S -
ig❑Burial Date A �] Ctery or Crematory
['Entombment - /� " ' q- V Ica) �ho rij A 1 I,
Address
remation �0 e,e1.1.5 J3 - A� '
Date Place RAmoved
Z ❑Removal and/or Held
and/or Address
w= Hold
Cri
0 Date Point of
Q ri
tin Li Transportation Shipment
0 by Common Destination
iiig Carrier
m ❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Npi Permit Issued to Registration N mber
PPPPP ArL ti - � � ro,, `
Name of Funeral Home � e rA �-S 1�
ia Address
( 1--e e'er— 1. S\ �� i a
Name of Funeral Firm Making Disposition or to Whom
04 Remains are Shipped, If Other than Above
2 Address
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Ili
] Permission is hereby ranted to dispose of the human _emains descr' abov as indi -)-d.
lip Date Issued Qr8 /y F Registrar of Vital Statistics.- 4._
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District Number sS' 15"--- Place ' \f\C' 4 'L-6-t - 1Miii
PPP I certify that the remains of the decedent identified above were dispof in acc. dance with this permit on:
Z p
I Date of Disposition $jfs/O Place of Disposition i��w L. ( or"'
2 (address)
ILL
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CC (section) A (lot number) (grave number)
el Name of Sexton or Person in Charge of remises ,1
/�� S'un1 elf
Z �/ lease print)
Signature G� Title 1l -
(over)
DOH-1555 (02/2004)