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McDonald, Barbara NEW YORK STATE DEPARTMENT OE HEALTH I Vital Records Section Burial - Transit Permit A Name First Middle Last Sex / Ai2- 6kP A• CYtc. oelA —t 1-a:P`! -1,,(.,= Date of Death Age If Veteran of U.S. Armed Forces, 3h217/A4`g. ''77 War or Dates f : Placepeath �, _ Hospital, Institution or utZ City,Joww or Village //e,j II41J L rUJIk Street Address V p SLDS l i J t�Ctof Manner of Death Natural Cause Accident Homicide Suicide Undetermined Pending tli Circumstances Investigation ill Medical Certifier N me Title G 0 $' C4 PPetttt4 PSI. b Addrress,� li011 P6 gerX a qt ! , Am (1A /4 4. /x. `3 Death Certificate Filed �_ District tuber Register Number City ow' or Village /i< 1 ib -(' — ❑Burial Date Cemetery or Crematory ,� ❑Entombment v3/Xcip.0 11 I j/tit 'VIi Ci2 1Vk/c`fi( Address Mii giCremation ()ES '3OIZy NtY' Date Place Removed 2�Removal and/or Held and/or Address E . Hold to 0 Date Point of tL Q Transportation Shipment G by Common Destination Carrier Disinterment Date Cemetery Address Reinterment Date - Cemetery Address Permit Issued to t„ Registration Number iiM Name of Funeral Home G bWi4-t2ti I_ , 1 1= 1 Kopt6 -i 4 L 0C-S-g10 Address ScA-E 12,co .1 ) A- iv i�. Ia i 7© Name of Funeral Firm Making Disposition or o Whom 1 Remains are Shipped, If Other than Above 2 Address c ti A: Permission is hereby granted to dispose of the human re ains described above as indicated. Ei Date Issued3/2X/// Registrar of Vital Statistics 01-1o�, -__. (signature) District Number /j 4,4 Place ,-e,4-,.,,-1 i 2,w I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: LEI 1- Date of Disposition 3 1°I-t( Place of Disposition fint�,.,�., C fat 7uti, 2 (address) Ili to tr (section) 11 s I (lot mber) (grave number) ai ca Name of Sexton or Per on in Charg of Premises ( 11 c,_Si i Lr selikktr z (please print) l Title Cal;Y� id.. in Signature . (over) DOH-1555 (02/2004)