Gallagher, Sarah t PI
NEW YORK STATE DEPARTMENT OF HEALTH- ik
0
Vitas Records Section Burial - Transit Permit
t>< Name First 30._rojr.1 Middle L I ast G r Sex F
<; Date of Death Age T If Veteran of U.S. Armed Forces,
fv; �-'Z 1 I ' 2_015 { (9,-( i W or Dates
e of Death � '�c j Hospital, nstitution or ��� F J tip%,to I
:. Town or Village treed ddress
r' T anner of Death Alitij Natural Cause n Accident D Homicide fl Suicide n Undetermined El Pending
Circumstances Investigation
Medical Certifier Name Title
igiltl
tik
it Address 100 - Q St. , _ C.,lp.+L0 F L.n, , 12701
-
.1. 6141
� �
Certificate Filed District Number 0 1 Register Number
Ci own or Village ( I
t� Date 12 3'4 Cemetery of rematory ,, P I(W- U
': ! Burial
E.Ore Address
/"--x) r to,) at (1s .11L�, . J 12 S�
remation ul
Date ; Place Removed
2 ❑Removal 1 and/or Held
and/or Address
r Hold
C? ! Date - Jint or'
N0 Transportation Shipment
- by Common Destination
Carrier
Disinterment Date ( Cemetery Address
Q Renterment Date Cemetery Address
Permit Issued to f ` Registration Number
Name of Funeral Home � �� � ��Q/ Horne_ 1 on j 0
Address
Rii Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
7' Address
I
A,.
v -4 Permission is hereby granted to dispose of the human r mains de ribed abov as indicat
Si Date Issued��)/� �,_ /_5 Registrar of Vital Statistics
]"` (signat e)
District Number J�Q/ Place � �� f / L
J
I certify that the remains of the decedent identified above wer disposed of in accordance wit this permit on:
iii Date of Disposition 7-079-15 Place of Disposition /Pt't7< 'e Cr c,,- eye a,y
2 (address)
ill
Sra
(section) (lot number) (grave number)
Q Name of Sexton or Person in Charge of Premises i i,via y rJn.eu/e
2 (please print)
Signature__ _____e j
Title crr,,.4:4 •4554--
(over)
DOH-1555 (9/98)