Mallette, Lucille NEW YORK STATE DEPARTMENT OF HEALt1-i If 311
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
6,cyc_itfl n'Ja_aes77`e_ 5 P/-
Date of Death Age If Veteran of U.S. Armed Forces,
d q-02 9- 2-.6/5 -7.- War or Dates
1 .5
Plac th Hospital, Institution or
City, Town r Village 171_0 cr0 �-- Street Address 1►?6S4 5 �b 5%� IU 't j hrm�
i Manner of Death INatural Cause DI Accident 0 Homicide Suicide Undetermined Pending
U Circumstances Investigation
iti Medical Certifier N me Title
ddres s '�---,
fG/r wi'eKy' Si- A l Coiudev-45A AJ2X l g ., s3
Death ' icate Filed? II District Number Register Number
City, own Village 11 Co iJd e 1�iw 6-- 151 O �f 1
to
❑BUrlal Date � e ry�or Crematory ._
['Entombmentd 7 - 3° .' �/, /Joe 01 €1.-0....,A 101-'`
m Address(
ation Ue-eJOS 6 ,vv)7 A)X
i
r
Date Place Removed
Z❑Removal and/or Held
P. and/or Address
M Hold
0 Date Point of
D Transportation Shipment
12 by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
`
E...d4A j Permit Issued to - /- 1 h� Registr j ber
Name of Funeral Ho e -c - / f vioe-vat / //
:::Address �� l _ /U71 / 9-, c5 --
Name of Funera Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
• Address
. :: Permission is her y g anted to dispose of the human remain s ribed ab e as i d cated.
'' Date Issued 7/, Registrar of Vital Statistics _ %I/ �-i ( :P/y eU,_--
--- (si na e)
<: 1�2Y / l l"U r?
li District Number Place ,r(
I certify that the remains of the decedent identified above were disposed�of in accordance with this permit on:
• Date of Disposition 'I/3c[sr Place of Disposition '( ,iLi Cm*<,,...
(address)
ll
0
1r (section) (lot number) (grave number)
0 Name of Sexton or Person in Charg of Premises /Ii, i
/ f(please print)
• Signature �i` Title thf ^•
(over)
DOH-1555 (02/2004)