Groves, Mary NEW YORK STATE DEPARTMENT OF HEALTH - '
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
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Date of Death Age If Veteran of U.S. Armed Forces,
'i / 3a 7 / 7 '7 I War or Dates —
Place of Death Hospital, Institution or f
Z it own or Village r� r . Street Address 'rf <
a anner of Death Q Natural Cal❑A den( -El Homicide ❑Suicide ❑Un ermined ❑Pending
U Circumstances Investigation
tu Medical Certifier Name Title ^y
0 I t �aA 6,„, 0A O
Address /I U y `
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Death Certificate Filed c—, Dis*ict Numbers V Register Number
ity.�own or Village JA'r-k,-t+ r..,y�- S�IP
L_IBurial Date / f I Cemetery or Crematory
['Entombment IVV-i//7 V i`�l c v,, � 6.-9-�r
Address `�
Cremation (X,A`t1 s j�-r 1'
Date 3 ) Place Removed
Z Removal and/or Held
9. and/or Address
H Hold
to
Date Point of
❑Transportation Shipment
f by Common Destination
Carrier
❑Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to -- _ Registration Number
Name of Funeral Hoe,,'.yn~)r` 1 e•.A 4 4 •• .-e-e--- Cu,`7"y1'
Address /^y r
Sk�.,�vr- duel C J r-I-3,-L-. Aft C o_ ‘( a-li
Name of Funeral Firm Making Disposition or to Whom
1.4. Remains are Shipped, If Other than Above
', Address
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Permission is hereby granted to dispose of the human remains desc_rib`ed ab as jndicated.
FilDate Issued .7'-27 /7 Registrar of Vital Statistics --�
(signature)
District Number 5-,.)( Place C-13 ) cra-�, S f �7
I certify that the remains of the decedent identified above were disposed of in accor nce with this permit on:
F 3
Z /
la Date of Disposition //(2$f i) Place of Disposition '�M�.
2 (address)
Ltl
CA
it (section) fit number) (grave number)
QName of Sexton or Person in Charge of P emises ' -_x. tr
z (plea a print)
Signature Title INfeei"��
9 �'
(over)
DOH-1555 (02/2004)