Mangelsen, Christel ft
NEW YORK STATE DEPARTMENT OF HEALTH �('c
Vital Records Section • •. Burial - Transit Permit
Name First // Middle Last Sex /
p L—. j G�P7�.F '!
Date of Death— � � Age/ '/ ��(,i Veteran of U.S. Armed Forces,
O? -/ -,2QJ/ j War or Dates
1-- Place o eath / Hospital, Institution or
2 C. , own r Village/5-;-',/ -c�JU/ Street Address '9 ca e, 0 a,"
W Manner of Death fNaturalausecident Homicide Suicide Undetermined Pending
Circumstances Investigation
W Medical Certifier Namer J 1 / ��/� Title
la 'foba�'l C-o Ve/ v
Address ..
•--7 o)') Cep. ',/ .G/co * A ./A/Y/ 8O/
Death Certificate Filed � I District Number Regiter Number
City, wn r Village / ) ���3 w S'Ito to a- /3.
❑Burial Date s'4j I Cemetery or Creimatory
❑Entombment ‘ //27.Z.0 / I `'"? (
e- ' e.,`r‘i C✓?"Y✓►4j
Address p
(I
,? remationv1 a./ .e,/' 0 �1 Pe 0SEeLi/7f ///'
Date i'Place Removed l .
2 Removal j and/or Held
21---j and/or Address
Hold
to
0 Date ! Point of
ft❑Transportation i Shipment
5 by Common Destination
Carrier •
El Disinterment Date Cemetery Address
Q Reinterment l Date I Cemetery Address
Permit issued to R----'_—"•-•••• Ms ember
Name of Funeral Home 0,\f nal d , _ c&key Rine raj ;yet_ o s //3 0
Address
11 LakyQHe_ SA. a L,LccnSNOLkry , Ive ,� yrL 12si0
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped, If Other than Above _
Address
w .
#1 Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued '', /g_ ,-o// Registrar of Vital Statistics gQ `�°
(signature)
District Number Alva_ Place mirk, ii �,r , n
t- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
Ili Date of Disposition y I11 itl Place of Disposition f?.,U,� I;
(address)
W
(section) (lot numb (grave number)
0 0
Name of Sexton or Person in Charge of P emises r,N r 1.4)-
5 //if-
i� (Please print)Signature �p Title mole*
/ (over)
.
DOH-1555 (02/2004)