Wecott, Maribeth NEW YORK STATE DEPARTMENT OF HEALTH f ram. it 9
Vital Records Section Burial - Transit Permit
Name F Middle Last Sex
irT d i-r d e tC1 ace re-004/Q_
Date of Death / Age If Veteran of U.S. Armed Forces
Q f —f 6 — f 7 o War or Dates /Ud
l-- Place of th //`'/ Hospital, Institution or
Z City, Tow r Village ( / er— Street Address . /Al " 6.e)-j m A t � I y/
0 Manner of Death iraNatural Cause 0 Accident ❑Homicide ❑Suicide ❑Undetermined Pending
MI Circumstances Investigation
tu Medical Certifier Na Title
a Su A,wUe - 10 MD
Address
3 .M pfivo ,3f,, tOlar td_s&ry KV, e6-5
Death Certificate Filed District Number / Register Number
City, Town or Village 2gf e'- S6-5 a--
❑Burial Date C tery or,Crematory
Of— /C"` �� tjNei/eft) t v-e A/ F >
['Entombment Address �)
" emation U,P-k. I ur,/ /'-S-2( '
Date Pla6e Removed
❑Removal and/or Held
9and/or Address
F_- Hold
(0
O Date Point of
05❑Transportation Shipment
0 by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to �` / r Registration N ber
Name of Funeral Home DOA kd L l` 4' T�Ii 00 114c I
, Address SIACTV)k--- IN 14 N
loil Name of Funeral Firm Making Disposition or to Whom
} Remains are Shipped, If Other than Above
,' Address
oz
t
` Permission is hereby granted to dispose of the human re a' s fl
escribed above as indicated.
Date Issued J - /q-,2C Ib Registrar of Vital Statistics C 01,&LU
(sig ture)
District Number ,S' ,(,, Place 10,,�;,Acr, 66 P Nam, L ptr-(
1 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
LU Date of Disposition I/(9lity Place of Disposition X Us-.0 �i- w1O(;`
2 (address)
Ui
to
(section) / , (lot numbe (grave number)
Name of Sexton or Person in Charge f Premises ">l+► ^u°'I
Z f(please print)
i a �� Title I7VL
• Signature
(over)
DOH-1555 (02/2004)