Masse, Louise NEW YORK STATE DEPARTMENT OF HEALTH "k It y l
Vital Records Section - Burial - Transit Permit
Name First j Mille Last See
L- c)Jse__l I se. I - try
s s
Date of Death Age If Veteran of U.S. Armed Forces,
/ 't/. c)j gd War or Dates
��- •f Death Hospital, Institution or (�
,! nor Villager S r,, Street Addressr�!`�1}v �JS'
D. � .nner of Death Natural C e Acci nt Homicide Suicide �Undet mined D Pending
Circumstances Investigation
W Medical Certifier Name n , . title
c.� A e.
Address
c 1 Al r +I-(. 90 % 1,40*-40T- S N Y 1044
eat Certificate Filed ( Distfitt member ,�/ Register Number
City own or Village ��r, -1,,,. TC,
Burial Date / Cemetery or Crematory L
DEntombment -4).„„i
1 ` S- °a (I ,n e_v �:a (.J� HT
® Address , t
Cremation �ul C S_Lr , `',"(
Date f /\JPlace Removed
Z Removal and/or Held
2 and/or Address
F_- Hold
IA
O Date Point of
tili Q Transportation Shipment
O by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to / Registration Number
Name of Funeral Home hM .4 S ax- e tY I
1 -1-''Me -1-."c o g
Address
/ S&aim•+^ Ave, 6r,‘ _. P i 1 a.<6 d-
• Name of Funeral Firm Making Disposition or)to Whom
14 Remains are Shipped, If Other than Above
2 Address
I
Ui
a` Permission is hereb/ granted to dispose of the human remain rib d abovg as indicated.
)/Date Issued I f7J ,y,U
(signature)
District Number 4501 Place SARATOGA SPRINGS
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I Date of Disposition �Lc 3i TN Place of Disposition a J n,J (_f tl.W..
2 (address)
LU
#f
CC (section) 4(.*-
(lot numbed-. (grave number)
0r J�h�tt
6 Name of Sexton or Per on in Charg of Premises
A (please print)
Lu Signature k Title (N•1 T,fla
(over)
DOH-1555 (02/2004)