Morse, Marilyn NEW YORK STATE DEPARTMENT OF HEALTH 41 3,1
Vital Records Section f`. Burial - Transit Permit
Name Fi Middle Last Sex
6 t fin_ 7/7
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Date of a th Age If Veteran of U.S. Armed Forces,
, 4 `7 A ?a) 9/S'- j� War or Dates
f- Place o ath Hospital, Institutio o � ,�. ;Li ,./4"/
City owyYor Village /7,ff v6 Street Address i G //'> te7
O Man er of Deathatural Cause 0 ccident Homicide 0 Suicide Undetermined ❑Pending
4. Circumstances Investigation
iLt Lj Medical Certifier Name Titl
A /1,, ._c- 6&()/ ifi . -64, ,c',,e .. -/-Y*-4 ,2,c9s---,73
Death ficate Filed District Number Register Number
City, Po or Village J7/ _.lic/c 5 4 S. la.
El Burial Date , .. or Crematory -
Entombment ��� llt / , 1 Cal fi A� � � /� (/t'� � i, Ll / Imo/
Address �remation V�-?-- /C 2 �,„C/7c2/.. /72.6eb,/
Date Place
Removed
t ❑Removal and/or Held
and/or Address
F" Hold
0 Date Point of
to Li Transportation Shipment
G by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q Renterment Date Cemetery Address
Permit Issued to �jJ Registration Number/
Name of Funeral Horn J a d� %%'1 I iIAte*.11�%i'G PIe9/C, f
_ Y
Address 7I/� e �� �G C�ij� ./U / '-P/ 7
Name of Funeral Firm MakingDisposition or to Whom
:
Remains are Shipped, If Other than Above
2 Address
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IL
F Permission is hereby granted to dispose of the hum re ains cegcribe above as in ' ted.
Date Issued 5 P�Z-o)ARegistrar of Vital Statistic II
(signature)
Mi District Number 1(.3 � Place ) ��AD -
I certify that the remains of the decedent identified above were disposed of in accordance with is rmit on:
Z
ILt Date of Disposition (.0/I 1 i S Place of Disposition E (),,....10--
2 (address)
Ill
CC (section) /j (lot number)f (grave number)
ii
p Name of Sexton or Person in Charge o Premises d'"" �" `�`""�
(please print)
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Signature Titlete
(over)
DOH-1555 (02/2004)