McDonnell, Theresa V
NEW YORK STATE DEPARTMENT OF HEALTH j A3 0 Vital Records Section Burial - Transit Permit
Name First I H U t i,' Middle An 0 Last M c Doririt ft Tairmat
Date of DeathoLA �7 Age If Veteran of U.S. Armed Forces,
U') L() t L War or Dates
Place of Death ,a/, Hospital, Institution or //��
z City, Town or Village M V V C a U Street Address �s pQt�Y �VC�CI
p Manner of Death Natural Cause 0 Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
W Circumstances Investigation
W Medical Certifier Name
CI
John stoutcr, 3„) , Title M'�
Address i (�3 �_J(�� 1( Sit , �crisi Fo 1 3a I\ y 120 )
Death Certificate Filed Iv(o le,a District Number T „z Register�N,u�mber
City, Town or Village s�I (
❑Burial Date May
CI ' j r�I�7_ Cemetery gri�rremat y� Con��❑Entombment vTf/ l•�
]Cremation Address I f 11 } rt J UU't� �-{„U\J l \N ( ��4-
�i Date l�1 V �1� ( Place Removed
J
z❑Removal _ and/or Held
2 and/or Address
...al Hold
CA
0 Date Point of
fki❑Transportation Shipment
G by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
PermitameIssued to �I nU(J l Ili
I Ian od `fn u L itRegistrationL `
Name of Funeral Home J U \ I V V'V W�' .v �l
Address, i / IJCti 4f)
rl
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
„g Address
t
ill
fl Permission is hereby g anted to dispose of the human remains escrib a ve as indicated.
Date Issued 65- 0,?)07 Registrar of Vital Statistics /
/ 7 (sig ture)
/e
District Number ` >CC 2. Place 057 Peq//70/(IS ci 4/./.e.Ci�j tL-f Jy T
I certify that the remains of the decedent identified above were disposed of in accordance with this_ permit on:
z n
t Date of Disposition Sf►r i n Place of Disposition 1"int\VwJ Grim'
aibattri,+...
2 (address)
W
Ul
CC (section) 1 (lot number)r. (grave number)
g Name of Sexton or Person in Charge of Premises t, ,,.g,n(;.r m i t
z (please print)
I Signature 2._ Title �t2�,NI ft
fir`
(over)
DOH-1555 (02/2004)