Sprague, Mary NEW YORK STATE DEPARTMENT OF HEALTH
65I
Vital Records Section Burial - i ransit Permit
Name First Middle Last I Sex
`` Mccr Eli zabefi►'► ot. I F
3
_< Date of Deathp I Age I If Veteran of U.S.Armed Fo es
O I Lo i g 5 { War or Dates
Place of Death ` I Hospital, Institution or 1,�
`-'�iirio own or Village G I MS Fo►1\S I Street Address Glens Fails -fibs();441
Manner of Death j Natural Cause ElAccident 0 Homicide n Suicide El Undetermined ri fl Pending
` i Circumstances Investigation
Medical Certifier Name �, Title
.-ro►nCCS 1 Ot 1 i vt.0�( l' S;c►a rl
Address J y
I CQ I Grey Ad 1_�enr burn AI 12 8051
Death Certificate Filed i Did ict umber " - I Register r
< - ira-. Town or Village G%,ers oX r I , j(�/ !-
Date • I Cemetery or Crematory
n Burial l QeS,OZ J 2.01Cp i Pine._ Vieth) Cce o o y
Address -
Cremation QJc�►v €- Rt a4 veerebury• Aly ?-soq
Date Place Removed
0 — Removal i and/or Held
, , and/or l Address
a Hold
Date _ Point of
u`Transportation,j Shipment
5 by Common Destination - •
Carrier
Disinterment Date ` Cemetery Address
Reinterment Date ; Cemetery Address
- - - i"
gi Permit issued to - Registration Number
Name of Funeral Home - _ /3j eot. g Gea, ,e" i 01130
Address
// Lair sTr r. Qum-4s a0Rat 1.. ago if .
Name of Funeral Firsn Making Disposition or to Whom p -
:.1 Remains are Shipped. If Other than Above
Address -
ilPermission is hereby granted to dispose of the human remains described above as indicated.
`' .
Date Issued S 12 116 Registrar of Vital Statistics
_<s; (signature)
ig;:: District Number 5,60 I Place 6 (sw's _i S ,1\1
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ento,„,
5Date of Disposition 1iLl((( Place of Disposition 6'► 4rN
2 (address)
th
M (section) (lot number} (grave number) •
Name of Sexton or Person-in Charg of PremiC:ises • 1:jji� Jt
Z (please print) f
>4 Signature Title CIVEAKP 4-
(over)
DOH-1555 (9/98)