McCasland, Minnie NEW YORK STATE DEPARTMENT OF HEALTH ��
Vital Records Section
Burial - Transit Pe emit
Name First Middle La t Sex
M C tti tt i e_. I� I,(c_Cu.L kaliAdl ffi
iDate of D ath Age If Veteran of U.S. Armed Forces, 0{4_
i �S(23I I I War or Dates
.14 Place of Death , j Hospital, Institution or
City, Town or Village 6 C AW�((I�- Street Address
iiici Manner of Death[/Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ri❑Pending
llU Circumstances Investigation
ig Medical Certifier Name Title
ge-AkUePeV. itakte5 IM ()
Address ri fi0!n inn ] C u4(Q_
Death Certificate Filed � rr District Numb Register Number
City, Town or Village OT— �Ui(f 4;2_ o2 I
❑Burial Date 73 I C1fP r I' Cemeteity or Crematory
['Entombment ( Nike V f 2�J wetM e b/ L (&
En Address
Cremation
Date Place Removed
Z Removal and/or Held
9- ❑
� and/or Address -
Hold
0 Date Point of •
%,* Transportation Shipment
a by Common Destination
ai Carrier
III Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
;: Permit Issued to - Registration Nu ber
Name of Funeral Home Oct
Address µ
Name of Funeral Firm Making Disposition or to Wnom
Remains are Shipped, If Other than Above fk B - Ctctik-- c-) '" /--
it Address 2310 , evt c- .A . tgke P(accc4 I 9'4
•
'` Permission is hereby granted to dispose of the human rema.i s es 'be. above as indicated.
Date Issued 151 295 f,I Registrar of Vital Statistics i\s s4
iiiN (signature)
iMiii District Number 57z.go Place V a(et Te cr- Ervatk tJ;(IQ_
1,,,,,,,,,,,, I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
tii Date of Disposition r/1,h( Place of Disposition rn,t,IL 6~1 14 $V
2 (address)
ll
CA
CC (section) 4 , numbe (grave number)
ci Name of Sexton or Person in Charge of P mises r� 4(lot
vr t"^c
(please print)
UiteL
Signature C�.�T Title az¢14 AT it-
(over)
DOH-1555 (02/2004)