Richards, Marilyn ..r n v'-2)
NEW YORK STATE DEPARTMENT OF HEALTH Burial Transit Permit
Vital Records Section
Name First Middle Last Sex
,� I .� �5�,) /( )G � S F�
18 Date of Death / Age If Veteran of U.S.Armed Forces, ,
<» j / l//6, or Dates Ai O
P e of Death os ,jtitution �'
City, own or Village Gter,)s POLL 1 S r Address (4 cr J 3 / .-j
anner of Death 1(Natural Cause Accident Homicide El Suicide Undetermined Pending
llti b� Circumstances Investigation
tu Medical Certifier Name / Titler-,:. ---. n
kl) d3'�r0 �/_Er'/ J A
. ) I`' I-- C
Address
/ 70 GJ 11'4-3 -. Q Ce,--rz Faus Al;V
B, - I Certificate Filed District Number . Register gum
L]!!::>eal.wn or Village �.p .) FILL S - w.�� J
r - .Burial Date Cemetey - ,
- 1 2 I / Co ri,) . w i e�
❑Entombment Address g-4,6
c;`<, Cremation 1}�?�6� Q 'b2��u I!1/t-Z.- /�J
Date Place Removed / /
❑Removal and/or Held
and/or Address
4. Hold
tili Date Point of
ot Q Transportation Shipment
zi by Common Destination
Ni_ Carrier
Q Disinterment Date Cemetery Address
:' Q Renterment Date Cemetery Address
Permit Issued to Registration Number
ber
= >= Name of Funeral Home H Gy nc r !0, maker F ,r of {k(r' _ 01 13 Q
Address
11 Lacal t e_ SA. , a kkeensbur y , NJ e v`i yc,r V._ 12 ci 0 LA
igi Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
I
US
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued I/ 20/ i 6 Registrar of Vital Statistics �ckAty-.Q, i-A.A4ZT-4,0-
(signature)
>« District NumberS&D I Place 6 s \\,5 y
i
:>;.>. I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
tki Date of Disposition I/nil Place of Disposition ,,9,�0r,._, tirryncio.
(address)
iii
IZ (section) (lot,number) (grave number)
0
Name of Sexton or Person in C ge of Premises AA Stool
zii►. /'� (Plse Print)
1 Signature L-C Title 6100-
(over)
DOH-1555 (02/2004)