Kingsley, Mary NEW YORK STATE DEPARTMENT OF HEALTH �'t,
Vital Records Section Burial - Transit Permit
in Narre
A First Middl Last Sex
Lnoksle RAIale.
Date of Death i Ag�A If Vete n of U..`Ar�med Forces,
b Ito - ) -IS War or Dates N 0
Place of Death Hospital, Instituti o I
City, Town or Village 6i\S Street Address {-C (S T, ®� ! ;
a Manner of Death :d Natural Cause 0 Accident 0 Homicide Suicide �Undetermined Pending
►U Circumstances Investigation
La
in Medical Certifier Name Title
t l}at t k.a%v) C,t,e c kir"- MI)
Address. .
G 5 lI5
eath Certificate Filed District Number Register Number
iiili City) Town or Village 1ein5 -1-rk i.k _ (Dal
Burial Date C�'etery o Crematory
( g ` / -) F"► ni 1cC3Lr r cfp
['Entombment Address
II Cremation S LLQOM J(k a j ky
Date Plac Removed
❑Removal and/or Held
and/Holdor Address
F=
Date Point of
tiD Transportation Shipment
a by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Reintermentimi Date Cemetery Address
in Permit Issued to � %--� Registration Number
Name of Funeral Home Kit l I <- �.n/ r' 1 HD r r te— v, t 9
Address Oaf -2 11 ) r)d t aA Lam. (tl
Name of Funeral Firm Making Disposition osition or to Whom
Remains are Shipped, If Other than Above
a Address
it
ii
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 5/j gr f a)17 Registrar of Vital Statistics Lj CA,Liry-•-R.
U
(signature)
District Number 5"(I Place 4,CQ�y,S,� 1 1 . ,A)\._„)
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k-
2
tit Date of Disposition 5119 fr7 Place of Disposition Rota./ G,rr or► ",
iN (address)
0
(section) /(lot number) (grave number)
Name of Sexton or Person in Charge of Premises /Z St�"^"t
(prease print)
Signature .�r. Title €Miff iZ ..
(over)
DOH-1555 (02/2004)