Colegrove, Marion 36
NEW YORK STATE DEPARTMENT OF HEALTH f ., . IllVital Records Section Burial - Transit Permit
mi Name First Middle R Last Sex
00 Ori0✓? cO(e, rove f^
Date of Death Age If Veteran of U.S. Armed Forces, /
" /(;) — 9 0 I( 1 War or Dates
Place of Death (� Hospital, Institution or /QcLY�4 -t (r,'(u /11044 -e
City, Town or Village /oW"l ui Jd )I s Street Address �,1<• aoc�( td , Nov1 Cvt,.►c,,ucf i�gs3
14
kfi Manner of Deathj�, Natural Cause 0 Accident Homicide a Suicide Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
0 je6r) /2e li / 4 . ),
iii
Address 37 4 7 4,414_, 843„2_44..._ ‘.)6.(4,,,,, ,it.Is w Ari/c2?es„s_
Death Certificate Filed /a )) District Number Register Number
1111 City, Town or Village n o J�J 11/156� 6- SS -S
Date C tery or Crema ory
❑Burial I— ,a v - aO I, tYc2 Vte;,..) vacs c-
Address
,�Cremation qme.,15-L ., / iLf /c o l
..� Date U Place Removed
0 L I Removal and/or Held
*�- and/or Address
LcHold
O Date Point of
N0 Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration_Number
Name of Funeral Home E 4 �G„� /4Q i "'?e"� U-yk Oc7aa
Address 10 t� L 7 0 C
Name of Funeral Firm Making Disposition or to Whom
E''� Remains are Shipped, If Other than Above
Address
L -
iiNii Permission is hereby granted to dispose of the human re a"s described a.Agitr as indicated.
Date Issued I- / t. - ( Registrar of Vital Statistics 'vJtaft-
, 2- ' LGi .
((�� -�-�(signature)
District Number a S Place /O LA.,-c)T U v r2,.r k cAi
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition JRRJZI 12011 Place of Disposition 2,1/0"." C ),qi d r,v._
2 (address)
N
CC (section) (/` „ (lot numb (grave number)
GName of Sexton or erson in Cha e of Premises r s to J�h n[�'�
Z (please print) _
PO Signature ��i4 Title at col A�vC
(over)
DOH-1555 (9/98)