McQuain, Diane NEW YORK STATE DEPARTMENT OF HEALTH D
Vital Records Section Burial - Transit Permit
>r Name First Sex
4,3 , taAJ L9r, /t _ 29tC.- Q U/9-7.^-) l`r/y4-z.
Date of Death I Age If Veteran of U.S. Armed Forces,
0 ! /3 A i S'7 , ^ . .r Dates „/ 44
"' 14 ospita P - e of Death stitution o Town or Village Q 6 ! Street Address 6 , noDi c+r�2 'i'L-1
3 anner of Death 2 Natural Cause Accident 0 Homicide ❑Suicide �Adetermined ri Pending
Ul Circumstances Investigation
Medical Certifier Name I` Title
CI 1- i a V A.) C ie-kr.0 4661 2 ,
Address] Ay/ /�J ///+�� /A�J/��
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Certificate Filed ; District Number f lc/l Aeg je 16I.A., is r N jbe
Ci own or Village 4ar----
Date t Cemetery Cremato ,)
E.
Burial 9 ! t ',hr. UI
Address
:::: Cremation a U OlC t'v\..:- ga , Q U Lam' (-47 it)/
Date 1 PlSce Removed '
8 El Removal ': and/or Hein --
I. and/or i Address
W- Hold -- -- -
O 1 Date P;;int of
fl Transportation I Shipment
Q by Common Destination
Carrier
1 Date y - s Cemetery Address
11 Disinterment I
:: Q Reinterment Date Cemetery Address
.
IF Permit Issued to �1 I Registration Number
igii Name of Funeral Home UaKe.Y .t...rterQ\ }\ci !, 01 ti 30
Address --
\\ t_G. olesrl-e_. S eer Q v.eensb;,k.rj , Wi 12- 04
s Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Ir
6' Address
>< Permission is ereby granted to dispose of the human remains described above as indicated.
ie
>g Date Issued /1 Registrar of Vital Statistics ,v,.L�',,__s_ C ..-� , ►LC .
gik (signature)
,ja District Number Q \ Place �^ _`- 0 P ` Kc,L
ithat the remains of the decedent identified above were disposed of in accordance with this permit on:
:�: I certify p
z Date of Disposition j/q(tC Place of Disposition P1.r ( �o
2 (address)
tLI
fn
EX (section) j(lot number (grave number)
dName of Sexton or Person in Char a of Premises #h, ilv
(please print)
4 Signature Title <r
A ON
(over)
DOH-1 555 (9/98)