Irish, Dorothy NEW YORK STATE DEPARTMENT OF }-,.."AL ' . . l! I U
Vital Records Section Burial - Transit Perri,
Name First Middle . . Last Sex F
�:` 0.^0 -4.,� . . -iris h
s Date of Death Age If Veteran of U.S. Armed Forces,
. 1e,b� L 2-0 ►( 9 S War or Dates 10
1 , -
Place of Death Hospital, Institution or
tty�Town or Village "f &t e- f -<<5 Street Address Glens c.-1.15 4-i osp r{J-I
anner of Death Natural Cause 0 Accident 0 Homicide D Suicide ❑ Undetermined 7 Pending
Circumstances Investigation
ilj Medical Certifier Name Title i
0 �e�..►, I�j oLir, � M (7 .
Address
(W 2 Pa..-k dress ,.e G-(.e..s ryA.,G(s NV ( z_ ko 1
illl! h Certificate F � e ins �-a 1 S District Number S G a ` Register Number
iilil; j
own or Villagiled a e
Date A Cemetery or Crematory/�
❑ Burial �"L ) 2-o f l "Pi 64.e..vi c w (ter e,, o r`r wry.
Address
Z Cremation 1 at..e,.ts b _ , N y
Date Place Removed
20 Removal and/or Held
and/or Address
• Hold
O Date Point of
NTransportation • Shipment
E by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address •
Permit Issued to _ I ' Registration Number
�♦''. Name of Funeral Home ��v+su•,o� {--t��( t-tow\t -t.
F•! Address
:k<
`'l; Name of Funeral Firm Making Disposition or to Whom
�ii
• Remains are Shipped, If Other than Above
';"2 Address
E {
piii Permission is hereby granted to dispose of the human remains described in`' at d.
<€ Date Issued 3)I /2-0 r I Registrar of Vital Statistics �p �f
(signature)
District Number J 0/ Place C i o- G (.e,v,s F& N( (s 1 Y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I,
EDate of Disposition 3 1.lu.u. Place of Disposition i' vi v i-ec�1 C fens cf.or v m
2 (address)
tU
g
tr • (section) (lot number) (grave number)
0 Name of Sexton or Person in Charge of Premises i rmcAk� brutie((� •
....j (please print)
Signature Title Ld e, kvrcj AS54 •
(over)
DOH-1555 (9/98) .