Harr, Mary l ZgZ
NEW PORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
N �a First C Middle f/a r Last le.
Date of Dea1th'' Age i If Veteran of U.S. Armed Forces,
`1 - / `1` CS War or Dates N A
Place of Death ; Hospital, Institution or
City ow or Village JOlin 5 bi) r9 I Street Address
Manner of Death Natural Cause 0 Accident Homicide Suicide Undetermined Pending
'/ Circumstances Investigation
t M cal Certifier . Name Title
R PA-
Addres
NICr`- - /
Death Certificate Filed 1 i District Number c-' Register Number/
City ow or Village ` Dhylsbl.t,,+'c 5 l IV ,
Date , etery loy Cremato
El Burial I q — [ S-- 101s Tine_ Vtat) u yY r
• Addr I
_' 2)Cremation 1,u0-+'t bt r
Date r Place Removed
Y _
CRemoval j and/or Held
F- and/or Address
r.' Hold
O ? Date Point of
Q Transportation Shipment
O by Common Destination
Carrier
n Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to 440-60--
-: Re stratoon Number
Name of Funeral HomeN (j/1'�, I o t i c
Address / _ 5 7 v k I oGi((.u1 M/ 1 Zgi-�
Name of Funeral Firm MakingDisposition or to Whom
F p Remains are Shipped, If Other than Above
laAddress
W
Permission is hereby granted to dispose of the human-re Bins d ribyA above a i icated.
Date Issued 9- 1� -6 Registrar of Vital Statistics
(sig } _ '
re
..;,, District Number J Place O t� �Th ,�0�nil, ,
certify that the remains of the decedent identified above were disposed of in accordance IV this permit on:
i'-
Date of Disposition �(I►4�/s Place of Disposition "ij... C vr...--
2 (address)
W
th
CC (section) pot number)._ (grave number)
Name of Sexton or Person in Charge of PremisesCI % tr4vf-
2 (please print)
al Signature et Title aiiviltIllat..
DOH-1555 (10/89) p. 1 of 2 VS-61