Bainbridge, Mary IP • ; 0 56 °
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle ,,-- Last Sex
1-Na,Yy I efcSG ; y- c:\c� F
Date of Death Age I If Veteran of U.S.Armed Forces,
°Sj l c b)201 lD c11 War or Dates N14
to-__Fta of Death r1Hospital, Institution or
Town or Village Street Address G)enS rafts -J4 Se -c
to Manner of Death N Natural Cause 0 Accident 0 Homicide 0 Suicide El Undetermined ❑Pending
W Circumstances Investigation
• Medical Certifier Name Title
Q �UZOXV(le., V\s col esla �v
Address
\DC) Pam & -Pt 4— , 6-Lan)- Fa11`� tan )
D-.: Certificate Filed 1 District Number a..)) Rogist Nymb
own or Village Flans rQ I 1 S c
■Burial Date Cemetery or Crematory
,1
❑Entombment Address
I
Og aO' l9 �', - e J"\C+� CQ`n1Cl--\'o'f 1
PCremation ( cv%v" Q Oft(\ Qv eeC1S\c)v4-` ,- iv-1 .lzg0 LI
Date I Place Removtid
Removal and/or Held
and/or Address
Hold
0 Date Point of
[J Transportation Shipment
is by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment i Date Cemetery Address
I
Permit Issued to Registration Number
Name of Funeral Home kit funifiL Al ti C3('30
Address
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Z Address
CC
ail
CI. Permission is hereby granted to dispose of the human re- ains described ab• e as indi•,
Date Issued �� '`n Registrar of Vital Statistics jJ f_i..... ` IC.
/� (signature)
District Number —) Place >i4"
I certify that the remains of the decedent identified above were disposed of in accor ance with this permit on:
ILI Date of Disposition 811 la Place of Disposition Ea,, Cc.—,
Lx;i (address)
0
j (section) ,„ (lot number (grave number)
p Name of Sexton or Person in Charge of Premises /4--r ,�ti.''�
Z please print)„
411 Signature a Title ("t)T► 14
(over)
DOH-1555 (02/2004)