Tanner, Mollie 11 71 2
NEW YORK STATE DEPARTMENT OF HEALTH , %
Vital Records Section Burial - Transit Permit
Name First •
ndle , _.Last . ex
fV( (l fey _I Q,h4
Date of Degt /, / Age If Veteran of U.S. Arm e)d Forces,
l /2.O1 �� War or Dates /vC
Place of Death f Hospital, Institute n or
Cyr Village �i�. .,�:� � Street Address 6(2O1 t i i s
d Manner of Death atural Cause Accident Homicide Suicide Und�mined Pending
U4 �Circumstances Investigation
W Medical Certifier Na Title
Q blkt, r4A y .
Address
�" Li IVY
Death Certificate FiileFiiledr , ` ` District Number 2 9 5 0 Register Number
Town P f'e,R ---_—,
❑Burial Date
(2127A30( rary erema o
❑Entombment �i
Addr s
[XCremation uee.,/`jcS6G y kj
Date 1 Place Removed
Z Removal and/or Held
9-❑and/or
~ Address
ih�
Hold
0 Date Point of •
&A Transportation Shipment
I
0 by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Li Reinterment Date Cemetery Address
Permit Issued to h/�C //�� ,/� � Registration Number
Name of Funeral Home /Vt l 1 f� C/ y
i.:::.:,, Address • Tk/C44-Ni t•A,t€7 NY •
Name of Funeral Firm Making Disposition or to Whom
1- Remains are Shipped, If Other than Above
'g Address
1
W,
Permission is hereby granted to dispose of the human remai described abo e as indicated.
Date Issued 20/ZO(5'Registrar
of Vital_Sta istics ,
TOWN OF HEMPSTEAD (signature)
District Number
OFrICt OF HE HE si
9 5 lace 1 WASHINGTON STREET
HEMPSTEAD.NEW YORK 11550
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI Date of Disposition 12-23-Il Place of Disposition Z1t1..-, C,•...% ',o-."
a (address)
lit
fa
CC (section) j (lot number) r,. (grave number)
Ci Name of Sexton or Person in Charge ;f Premises i r k..)
s
2
d. lease print)
uja Signature '4 Title ellf rIfilal
(over)
DOH-1555 (02/2004)