Eagle, Pauline NEW YORK STATE DEPARTMENT OF HEALTH! ' ' L T13
Vital Records Section Burial - T r a n s i t Permit
I Name First n i Middle Last E Sex
b Valid i ne. a,40\1C._ i-L-....-
ia Date of Death Age If Veteran of U.S. Armed Forcer,
10 - 2.5 - 2-015 9 I War or Dates kl) R
4 Place of Death Hospital, Institution or Gait/
ill Ci , 'ct n r Village Mov 4-V1 CreeNt. Street Address Pthirontiack.. Tri -Cv,n4- f-kg V)
. '
Manner of Death 49 Natural Cause 0 Accident 0 Homicide 0 Suicide 0 Undetermined r-i Pending
Circumstances 'Investigation
Medical Certifier Name k
\_) Title H b
9 a F. -1-1 inc. on
v,::- Address MR— 't"\:, gOL-I6\ c2_(-)0.d A (){4 vt CAOkiL ii"
Death Certificate Filed District Number Register Number
1 City,.1E5 or Village Mori-VN Cie 14.-
Date i Cerletery or Crpmatory
:. 0 Burial IV/ 7-10 I /5 r i n-e 1 II e id rr e aiikyy
Address
Cremation Q t.p .c‘ttv R bat( 13 r. I
Date Pla emoved
2=Removal and/or Held
2 L--land/or
Address
.-- Hold
Ft;ni Date TT-Doint of
j cn L Transportation I Shipment
a by Common Destination
: : Carrier 7
.....
Date Cemetery Address
Disinterment
Date 1 Cemetery Address
Reinterment
Permit Issued to Registration Number
itt Name of Funeral Home Zaker Fcknercd hOrre_ of
11 Address ii tarcuottc , , . , lax AI V 1 1 AY/
or , 6/ukcnS aj r eLo or t.-
g:'
Name of Funeral Firm Making Disposition or to Whom
iRemains are Shipped, If Other than Above
IA Address
ii
Permission is hereby granted to dispose of the huma re ins scrib d above as' icated.
E Date Issued /0,, /,•0-( c Registrar of Vital Statistics
di ( nature)
••::::,,
I District Numbe5(0 ..__ Place .\ 4rbj
I certify that the remains of the decedent identified above were disposed of in accorda with this permit on:
f4.
EDate of Disposition /0 /rPjlr Place of Disposition Pine,tit./ rremurtor,.....-
2 (address)
0
,cr (section) h(19_t numbeky (grave number)
‘j Name of Sexton or Person in C ar of Premises 0 t No lit— L.)trot
Z ill ge (please print)
4.! Signature Title (UMW
(over)
DOH-1555 (9/98)