Dowd, Muriel NEW YORK STATE DEPARTMENT OF HEALTH 60{-.)
Vital Records Section r Burial - Transit Permit
Name First A A Middle Last Sex
ini-AP : -L .) , U w C\ Fc/.,gl�
Date of Death / Age If Veteran of U.S. Armed Forces,
1a,, / G � 'l\ 7 War or Dates -_�
of Death T Hospital, Institution or
City, wn or Village (� ,, T«ti5- 1 Street Address % ,`., Al ,s .
nner of Death Natural Cause Accident Homicide Suicide 0 Undetermined Pending
W Circumstances Investigation
to laMedical Certifier Name Title
C4 1...) 2 i 1 A^•‘. A/47.9.,_ el b ,
Address � l j f,
.- A y
gott-
i-- 4 Certificate Filed District N dnber 6 Regi(erjNumber
City, r.wn or Village C. Le Rut - 50 1 S ),1
Burial I Date Cemetery or Crematory
.�
❑Entombment ) / 55 /d.0 I 1 1 , >1 e i/ ',V ,,., , Cc .1/4-t-�r
Address
aCremation n ��e.tis.b'r 1A ) jar/(
Date ! Place Removed
Z Removal and/or Held
0L—I and/or Address
CO Hold
0 . Date Point of
N IDTransportation Shipment
Ei by Common Destination
Carrier
Disinterment Date Cemetery Address
Renterment Date Cemetery Address
Permit Issued to _ — Registration Number
Name of Funeral Home ��,,\5,,,,ic.. —1—,aAe,., ( -).-i.e J— - 0 b 4'D b
Address i
) l
/ SI)ofvvls-, ,e / ' r , N, / / 1 d,..6r),").-
Name of Funeral Firm Making Disposition or to Whom
1 Remains are Shipped, If Other than Above
2 Address
CC
W.
Permission is hereby granted to dispose of the human remains described above as indicated.
NI Date Issued I)-../S/1 t Registrar of Vital Statistics CA-Alp-SC W-A-
(signature)
Ni District Number 5(Q i Place 6 (2,....,S c`\� J N
' I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Q.))IA.JDate of Disposition rift,�IZnl1 Place of Disposition Cnivvid/4--.
2 mot=—'+ (address)
til
til
; (section) t
mbe (grave number)
� Name of Sexton or Perso in Charge of remises _ ri �r 4I
print)
Signature LTitle
(over)
DOH-1555 (02/2004)