Marcotte, Charlene NEW YORK STATE DEPARTMENT OF HEALTH • l #3bq
Vital Records Section
Burial - Transit Permit
Est uL.. Middlemay_ Last i Sex
Date of Death Age j If Veteran of U.S. Armed Forces,
--/3 j� O War or Dates
44 Place of Death4_7 lift-KK/3 fi- e I Hospital, Institution or
City, Town or Village ize az.,erne_ I Street Address
Manner of Death atural Cause Accident Homicide _Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
i}-f c-d- �Z h1? S Cfn
/3 7aAddress
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Death Certificate Filed ^ �,�_ / - District r Register(,umber
i: Cityrow r Village L, r1Lrr-L C, -�
Date Cemetery or Crem y
�:�: El Burial G .1c162 - ,n 0-->/;C.-- 42.14 r
Address
�� ri5� ;r ;�NCremation L,) / , L
Date (J Place Removed
0 ❑Removal I and/or Held
-• and/or Address
l
Hold
o Date { Point of
N ❑Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Mii Permit Issued to f Regist�atior� Nu,er
-D Name of Funeral Home e ie I�lit{'luuck UO k
Address
v] 7 _5_he-04f1CUr\ il-Zie, 0,0,-,n q4--) r) j, I DI-e.ov
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
te
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Permission is hereby granted to dispose of the human r ains de ri ed above as indicated.
Date Issued _5—J10—f ( P Registrar of Vital Statistics aA
/ (signature)
�District Number Place WCQ L-U. �Q r71
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 5(I S1/L Place of Disposition at Li 00^046".�
2 (address)
LU
CC (section) got;r1Fbej.), (grave number)
GName of Sexton or Person in Charge of Premises A `� (please print)
W Signature Title Cl ►d{`( 4-
(over)
DOH-1555 (9/98)