Dickinson, Martha NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
pi Name First A ,lax+ Middle A Last -- i t,nSon Sex F
Date of Death f'9 ' Z_a IZC�1_ Age .� , I If Veteran of U.S. Armed Forces,
War or Dates
6. Place of Death 1 Mee - stitutiory�r
ow :•- 1,...
C V�C1 i \e I Stfeet Addrecc-
II CL j(t NOU-
Manner of Deal (Natural Cause Accident Homicide Suicide Undetermined Pending
iA "'''''�� Circumstances Investigation
29 Medical Certifier Name Title
Noel\e_ S�reven s M
Address
)vo j? 3\ ei Ven Toi s, 1\N1 vz_ o l
z Death rtificate Filed i District Number 1 Register Number
illi-6;ty;(7w e G-1+ranv.\. I c5 5,Le I 2
Date I rematory� p< ID � 'Burial 11 _ 1119-v ►ems
Address
:Cremation ( .-- -r" 2a . Q Urns h-i-, -A--. )j%j 'Z.`3ULl
Date i Place Removed
Z❑Removal I and/or Heici
,.. and/or — - --
172 Address
CO Hold
0I Date ----- - ---_-_---- -Point of � ,
NQ Transportation i — j Shipment
75 by Common Destination
Carrier
C Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to
Name of Funeral Home Baker f- uleccz/ home_ Registration Number
Address i o' ) 0
li Lar yettC of. , bc,tc..c osbu.ry ; Al au L/vrK lago/
Name of Funeral Firm Making Disposition or to Whom
"" Remains are Shipped, If Other than Above
Address
WI
t
>i Permission is hereby granted to dispose of the human remains describe• above as indicated.
gli Date Issued (2 13a 1206 Registrar of Vital Statistics ,► : , I
/ nature) % 1 ,
00.5
District Number 5 rlSp Place 1-6c.Or\ 6 F C� 'I< 1 Ile_
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
EDate of Disposition -}-/-1 S Place of Disposition Ca u e c.J cverkicei air t J$i
W (address)
1�
1C (section) (lot number) (grave number)
0 Name of Sexton or Person in Charge of Premises 1 M A-1k, it vnel
2 ."_� (please print!
41 Signature 4.c Title Cpem&(ory 1465
(over)
DOH-1555 (9/98)