McNamara, Helen NEW YORK STATE DEPARTMENT OF HEALTH L+
Vital Records Section Burial - Transit Permit
Name 1 M First, Midge-1 Last Sex
Nelep M,")i1'VW A 64,1A/ems
Date of Death Age If Veteran of U.S. Armed Forces,
0 -o a-- // Q'' War or Dates I�iJ
1 Place ath Hospital, Institution or
Z City, own r Village I c%t/td d erel A Street Address /)ic es Lt4/4 T� Pc.Arsitiff
O Manner o Deathjatural Cause ❑Accident 0 Homicide 0 Suicide ❑Undetermined 0 Pending
IUD Circumstances Investigation
iti Medical Certifier am�j Title
0 r nth r L n1 c_.,le'e-,-- ✓M
Address
/O1cj Wt"cj�r 3/- iGv,ic6e03311• All,— / a 'Fk3
:gi Death C ificate Filed District,N uo bee Register N b rr
City, own or Village ), Can 9
.d ev0 A SO
❑BUrlal Date 0 — °V- Q/ C etery ora Crematoryp
�' CTV / wQ— rl
El Entombment Address au / \ ,DI I4Cremation ee iti 4 c,'r/ N'7 '
Date Place Removed
• Removal and/or Held
... and/or Address
t Hold
U)
0 Date Point of
ti Transportation Shipment
5 by Common Destination
Carrier
Disinterment Date Cemetery Address
Q Reinterment Date - Cemetery Address
Permit Issued to Registration Number
Name of Funeral Ho e&upr1 1,. ` C?-/ Nt(A ( N° ' 005-1q
z> Address 1 /
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
;s Address
0
W
?` Permission is hereby granted to dispose of the human rema' s described above as indicated.
Date Issued /0/03 (30 it Registrar of Vital Statistics ` ' QlL.e-4---
(signature)
District Number . j (r Place k, I COX) Q VG 0/1 NT'
I certify that the remains off the decedent identified above were disposed of in accordance with this permit on:
2
III Date of Disposition 10- .--t J _ Place of Disposition Ph e,_t, Eko c eyvIceto , ;
a (address)
tii
CO
CC (section) (lot number) (grave number)
ci Name of Sexton or Person in Charge Premises (try!p 4(,, Ora n e//C
(please print)
iii
Signature c rt2 1324,-2.At. Title Creit i`-iof7 sS •
(over)
DOH-1555 (02/2004)