Jinks, Mary • la # 7IS-
NEW YORK STATE DEPARTMENT OF HEALTH Burial ® T�`aC6SI'� PermitVital Records Section
1 Name First Middle Last Sex
N1 VA ne 1 nos
I � c-
:::; Date of Death Age ,t 1 If Veteran of U.S. Armed Forces,
War or Dates Nv
( Place of Death ' Hospital, Institution or
7 City,ier• or Village HO( eOJ,..A- Street Address 5J le 5e`cr -Re
0 Manner of Death n Natural Cause Accident n Homicide � �
Suicide Undetermi d Pending
W Circumstances Investigation
U
la Medical Certifier Name Title
a v id n In man Ater, Physicue)
Address
.O 1 r-O(lilLt4� ,n C�t r,
Death Certificate Filed �J District Number Register Number
City ow or Village M O;e W.-J.- V S(o 2. 3/
❑Burial Date Cemetery or CrematorY�_ \'
❑Entombment \ I Za LD `Y�1;1e V•1e� CceC`'
Address
Cremation Quza -1 ic,„4 , (.u-e-enS bun ( Li. I 2-21611
Date i Place Removed
2 C Removal ; and/or Held
and/or + Address
Hold {
Date Point of
Q Transportation Shipment
is by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Reinterment Date I Cemetery Address
-1:- Permit Permit Issued to Registration Number
Name of Funeral Home .�Zt=-c ,' t—i \ kp -1 '�
C�:i 1 .,L-
Address Si
kx L:Sc�� ��-- C.N (e2,,s\u: 1 , Ny tz(,ct
Name of Funeral Firm Making Disposition or to Whom
_ Remains are Shipped, If Other than Above
• Address
EC
w
Cit
': Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 9/3Q//4, Registrar of Vital Statistics %� [ 1,_ `d/Za-4---
(signature)
District Number y Sto Place L✓i1 al /40.Cl a(.ti
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ill Date of Disposition 1014 lib Place of Disposition tV it-, (c i zko ftc..i
2 (address)
LI
1.. (section) (lot numbs (grave number)
raName of Sexton or Person in Charge of remises r.r f t t v1'g
Z ( lease piing
Signature A Title retompt
(over)
-
DOH-1555 (02/2004)