MacDougall, Alma - 4IV t f c--J YORK STATE DEPARTMENT OF HEALTH , . `. `
Alri..., Records Section Burial - Transit Permit
Name it t k , Middle ` _ _itt DQt(Dk/J
st exltait
Date of eath Age If Veteran of U.S. Armdrces.
9.--� --go)) q 1 War or Dates
Place of Death j Hospital, Institution or ``�� ,/
Cito T or Village ♦�J I Street Address 3560 600 4 I7&LL_ kd
ManneTsf Death 141K7tNatural Cause Accident Homicide Suicide Undetermined Pending
.':.i
Circumstances Investigation
Medical Certifier Namtyill Title
Address
[.<ti Death Certificate Fi ed ! Di rut umber 1 Register Number
City. Town or Village .��� ) # "iDDI- i
Date Ce tery or Cremato
❑Burial s 7off'l
Address
Cremation iJ
Date D� Place Removed
P. Removal I and/or Held
and/or Address
Hold
0 _ ; Date Point of
0 Transportation Shipment
C.� by Common Destination
Carrier _
Disinterment Date Cemetery Address
Reinterment
Date Cemetery Address
Permit Issued to ^ J 1 âUai
gistration Number
Name of Funeral Home ,C_,Lv.p_A QA 1 a_ -- Y)�(0 ,V1^. -
. Address
a9
',:; Name of Funeral Firm Making Disposition or o W om
Remains are Shipped, If Other than Above
Address
iti
fki
Permission is re
re y granted to dispose of the human remains des 'bed above as indicated.
`< Date Issued CI 1 1 Registrar of Vital Statistics C" . 0 d �
r--� (signature)
District Number 4 `1", Place ODLAn- n-6
J
I certify that the remains of the decedent identified above were d posed o in accordance with this permit on:
Disposition Place of QM(LW eis-at d f 10b•.
Date of Disposition ti $���
(address)
(section) .. (l t number (grave number)
of Sexton or Person in Charge f Premises t�>4 �
Ali
(please print)
Title Cat M 1ktbL
;. 1 of 2 VS-61
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