Macauleay, Janice NEW YORK STATE DEPARTMENT OF HEALTH ,. M(''
Vital Records Section Burial - Transit Permit
><< Name First Middle Last Sex
0,(\ is e I-A . McAcautkay F
»::: Date of Death 1 Age If Veteran ofU.S. Armed Forces,
to q I I , War or Dates
Place of_Peath Hospital, Institution or J
City, ow .r Village s► / - Street Address 3 o TJ); Yl t & -6
Manner of Death a Natural Cause D Ac ident Homicide 0 Suicide ri Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title ��
0 �a A;r tck tAt v Pr e Wi (1.9 'Ph ys;< tc(n
Address
\Lt 1 C Qv�-Q tnS\o0s( AH labLi
ft Death Certificate Filed tt ^ District Number Register Number
i:Eli:a City,�r Village CjU,QQ1(t 3k?O/1- ( sU 51 t U,��
Date / Cemetery or Crematory
El ' a Burial I CI I t 5 P; n e Vie 3 l n
r\o t'Yi dYy
Address
: 04Cremation C o,.ki•Lr. '(k-60a VLS `bC4-1 i'J I LEO
Date i PlaQW-Q,
moved
0 LJand/or al — -- i and/or Heitz -- —
p Address
a Hold
Date — -- r'omt of
N0 Transportation j Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date j Cemetery Address
Permit Issued to
>s Name of Funeral Home `Baker Fc,cneca-/ noire__on-�� Registration Number
1 Address // tar
y� � . , b�tcensbury , Alec,� `/Cf- 1a�0y
1 Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 1019 !2.0 1 S Registrar of Vital Statistics , + - .),-QP. ,
(signature)
Ng District Number 5 4 51 Place V1 U C T S bv/'
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
f.-
fDate of Disposition la sl13115- Place of Disposition T►µilL Cov.41-dr„.�,
W (address)
th
Cr (section) ii/lot number (grave number)
GName of Sexton or Person in Char a of Premises 14r,,tj,. )i.M.ef
z (please print)
t : Signature Title ((rl_M4Vit_
(over)
DOH-1555 (9/98)