McCaffrey, Cecelia NEW YORK STATE DEPARTMENT OF HEAL
Vital Records Section Burial - Transit Permit
'':€> Name First Mi dleM Se
J` Date of Death Ag If Veteran of U.S. Ar d Wces,
/0/t Y l a o i s War or Dates
"!' Place of Death Hospital, Institution or r
City, Town �Villaik t- � Street Address D,°3 t)K✓c ,i
Manner of Death Natural Cause 0 Accident 0 Homicide El Suicide ri Undetermined �Pending
Circumstances Investigation
Medical Certifier Nam Title
r ... ^"' �/� ,A/tJ
Addr ss
Care lane 1 ,.5... 30? i .Lt...' --St N i / ?w6L
iiiiiDeath Certificate Filed //''�� District Number Register Number
iiRCity, ow r Village t.-(-- - d k
Date �.- Cemetery or ematory
El Burial I o/Il /.101 rn eV c ..,) Cte,»„C-o,-y
Address
:> p�( Cremation C.--let).- 5, U.t ar✓(
Date L Place Removed
g ri Removal and/or Held
M- and/or Address
Hold
9 Date Point of
N0 Transportation Shipment
G1 by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to : � Registration Number
Name of Funeral HoC S,y.,mc Ae r.. /t jr.t.. 6c)ire.
i Address ✓
7 gr..4., Ave
7 6.4.7---- --__-' N ( /.2 IS,?),
•'••••r Name of Funeral Firm Making Disposition or to Whom
. " Remains are Shipped, If Other than Above
.46
. Address
ILI
iiiiiiii Permission is hereby granted to dispose of the human re described in
dicated.
a
Date Issued c/b 11 /i'c Registrar of Vital Statistics z C _
(sig ture)':<'`: District Number. �l Place �f�t. ) Al y
r...
I certify that the remains of the decedent identified above were disposed((�� `of in accordance with this permit on:
5 Date of Disposition 10/2o//s Place of Disposition .Y' tk-o ' i4rw-
2 (address)
iLt
U)
CC • (section) i (lot nim�ber) (grave number)
GName of Sexton or Person in Charge of remises /4; •- J`"'"er
g 4 (please print)
Signature Title alfiling
(over)
DOH-1555 (9/98)