Rooney, Alice NEW YORK STATE DEPARTMENT OF HEALTH m 7� t
Vital Records Section Burial - Transit Permit
Nam First Middle Last Sex
MI ice S Roone� -Wma le
Dat of Death Age If Veteran of U.S. Armed Forces,
Lit "2.? l (D 7 War or Dates kJ('
- Place of Death Hospital, Institutio or ,._
W Cit Town or Village G 1.��5 Street Address v.0 5 kits -140
ilk Manner of Death Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
W '-�'! Circumstances Investigation
W Medical Certifier Name Title
0
Address
Death Certificate Filed j District Number Register Number
City, Town or Village (3 �e i°)S Tali, ' i-1 q Z
I Burial Date . '-f i nmeetery p/Crel r nai
DEntombment Addres ( v «�Je , lam/
Cremation n,,,,,,..0 ha (24
Date lace Re oved
Z� ❑Removal and/or Held
and/or Address
f= Hold
ff)
0 Date Point of
0 Transportation Shipment
Et. by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
.0
Name of Funeral Home Bic f- - ( ,re{ I fOj' I YJL QQ ,�/
Address c� �' La 6_ Lt px 7u Ny of 67 l0
Name of Funeral Firm Making Disposition or to Whom `
} Remains are Shipped, If Other than Above
Address
Lu
97 Permission is hereby granted to dispose of the human remains described above as indicated./
Date Issued q I�1/t6 Registrar of Vital Statistics W GlA -)-- `, L,�,,ti�U
(signature)
District Number 56 0 i Place 6 (?„ S Fe, `\ S N }
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k
Et Date of Disposition q/3p f/Q Place of Disposition p7) , (..),-e..14.) Ce/e j vi 44rt/
2 / (address) /
ill
U,
CC (section) (lot number) (grave number)
0
G Name of Sexton P son • Charge of Premises �1 LA.. I C.,v a4Y2 ad,e
(please print)
E Signature Title Gft?yYl4
(over)
DOH-1555 (02/2004)