Pearsall, Margaret NEW YORK STATE DEPARTMENT OF HEALTHc)c.)
Vital Records Section Burial - Transit Permit
Name First Middle r.,Last Sex F
Az. ta�C,.p t IL 12 ; vc425A�L___
Date of Death Age If Veteran of U.S.Armed Forces,
�/ Sao ) O War or Dates
Ple of Death Hospital, Institution or
'` ' , Town or Village (�L F.►s s VA 4-J -5 Street Address 6 L� 5 V'A�--L_5 N as$ t T P L--
r Undetermined Pending
of Death ud.Vatural Cause 0 Accident Homicide 0 Suicide
rq
Circumstances Investigation
Medical Certifier Name Title
1A)) o SuPbEeL1.►- M7
oil Address �+ 1 � 0
I D 41k�-S v t.�t-$5 A``S r 1 -'0. Death Certificate Filed District Number Register Number
1,4 City,Town or Village G . iv.s C-&'-- --S K-6 C) ( r q 7
rr--�t Date em Cetery or Crematory
L..kBurial 3 �� C�a� >_S 1', 1`.w CcCo-N a c2 `‘
Address
Cremation NS�35Q`1' 1�— `� aq
vc.x�R ;�
Date Place Removed
❑Removal and/or Held
'� and/or
•• Address
Hold
6. Date Point of
`• 0 Transportation Shipment
ai by Common Destination
Carrier
0 Disinterment Date Cemetery Address
0 Reinterment Date Cemetery Address
: Permit Issued to t Registration Number
pi pi Name of Funeral Home i O rd a. �Qker Funeral 1-}Ome. of' 30
:: Address // Laf'tzyd#e c • , btA.Q i✓nS1OL1-+ r Nuo thylt-- l Q ay/
gill
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
z
Address
irri
II Permission is hereb granted to dispose of the human r sins described above as indica
kJ Date Issued Q, lI aoi Registrar of Vital Statistics _7f Q c- -797 ��
(s a re)
District Number �f�G l Place A
I certify that the remains of the decedent identified above were disposed of in accordance ' this permit on:
Date of Disposition 3 O -LS Place of Disposition 11 ew' Cise wvi wA-dr L,,vh
(address)
1
,y (section) (lo number) (grave number)
GI
Name of Sexton or Person in Charge of Premises t ,��-h, l7t`J heal
,_�--� (please print)
Signature U-4.A. - Title (Ire wi.c cy Asylf
(over)
DOH-1555 (9/98)