Fulston, Mary NEW YORK STATE DEPARTMENT OF HEALTH g)t(
Vital Records Section Pi* Bu °iai - Transit Permit
'f Name First ii A Middle Last ( Sex
iiiiiIii Date of De4th I Age 1 If Veteran of U.S. Armed Forces,
7/ 2L( Jir" 767 1 War or Dates ` A)/ ✓d"
.14.,,- Place Bath Hospit , Institution r { 11
Z. City, Tow r Village UE-CA .s Q I Street A (/V6, i r1OU�� �j'/ ,Ez-.
gManner of Death'Natural Cause Accid t b Homicide D Suicide D Undetermined El Pending
ilU Circumstances Investigation
Medical Certifier Name. QS n 'OL Title A ,D
K.f Address C w rizi La-1V. ) o lbro_.._L i .lam 12-gQt..4
<:: Deal ' icate Filed ? District Number 5,� 1 Register Number
Ci To r Village 0f AS a 01 I 13 (
Date I Cemetery o Cremato , / )
❑Burial -2/2._."? j/S— 1 i u tc V! &I-3
Address / �/
.::_:ECremation & L.) •1
OW_L -.. I /3 u -zr u c 3 1U
Date i Place Removed � /Z ❑Removal I and/or Held
r. and/or Address
rct Hold
O ! Date - - i Point of
Nn Transportation j Shipment —
a by Common Destination
Carrier
Date I Cemetery Address
::: ❑Disinterment
t l Reinterment Date Cemetery Address
Permit Issued to , Registration Number
AI Name of Funeral Home ZQker /-u-ne1Ccj //Ome. { Of 13L
I
Address 1% Lao ctte of, , buu. sb rc , /Ue,w L�U!)L /aA) /
�i. Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
IC Address
411
AU
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued -'I 12.g (DIDI Registrar of Vital Statistics --SIC , 1 -A-\c).- -/
(signature)
District Number 5 4 5'I Place GJ U-c cns b U i
I certifythat the remains of the decedent identified above were disposed of in accordance with this permit on:
P
f- �
fDate of Disposition ?--3i�-/5 Place of Disposition L `','1e -i 1Pc.,./ C-irre014-4atw)1
2 (address)
LU
in
CC (section (lot number) (grave number)
O Name of Sexton or Person in Char e of Premises I i w-o 't (arvn?�(.
g (please priiht)
1 Signature Title Ci'emA.4p(17 0551
(over)
DOH-1555 (9/98)