Coyle, Marti NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
riti Name First Middle Last 1 Sex
�-Iar� �10( �o�`n Co r� {
Date of Death lZ i3 lS 1 Age �L( { If Veteran of U.S. Armed Forces
``3 l I War or Dates \ies_
Place of Death 1
Hospital, Institution or I
y, Town or Village l-\�S -q\� ! Street Address e cvs i
Manner of Death Natural Cause n Accident 0 Homicide Suicide Undetermined El nding
W C n Circumstances Investigation
111 Medical Certifier Name Title
41 Sea rl em`t iii
Address !�
!:5 \OD Rhr\L S -1-- Ole its RA\\s
a Death Certificate Filed I District Number 1 Fiegis r Number
'� "own or Village oSVj\c1 5 6° ( I 5 9 I
Date , I Cemetery or Crematory
:::: C Burial l Z I rj J s ` i )� u Pv 0-e tm6H-6(
Addres )
Cremation b__),±i- 0
Date ',: Place Removed
C Removal ' and/or Held
and/or — — — --- —
�;. Address
(40— Hold
0 ! Date i r—;int of
a[J Transportation i 1 Shipment
a by Common Destination
Carrier
Date CemeteryAddress
0Disinterment
i
U Reinterment Date Cemetery Address
!! Permit Issued to — ` Registration Number
Name of Funeral Home Baiter J-u ercc/ //om _
1 Gt ) • U
>' Address i•j La Cti" to • Csr(.t t e,r)SiaLi,r '
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
a` Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12 /Li//5 Registrar of Vital Statistics L
(signate.re)
District Number 560 / Place 6 S To, \\S, N Li
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
E Date of Disposition /24(,-/5- Place of Disposition P41..e U le..u.i re ,A,lo7
w (address)
to
0 fr (section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises ,J�Ire,gi n ‘A knet,a e.--,
(please print)
Signature Title G fse- 4 04.
(over)
DOH-1555 (9/98)