Foganty, Shirley tt (I a
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
—��, = , /=v c,�,,,r-- few
Date of Death 7 J Age If Veteran of U.S. Armed Force
a)//3 /Z. -. 1_7 _____._. War or Dates
I- P ace of Death Hospita nstitutio9Abr ZilDi Town or Village cL(s)_shu, reet Address Li G(aAj S reit S
p V anner of Death 64 Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ElPending
W Circumstances Investigation
W Medical Certifier Name Title
GI ra_g_1791.A) 6 kgftfo-c_ itiZ
Address
/0 2- e97,,,,_ S;--_ C tr,o_s fe-,,s_
las°, _
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•-.- h Certificate Filed ' District Numbe • � Re ber
own or Village �ar Dv.. S 1 c
■Burial Date Cemetery or Crematory
P/�y2- .vFJ U4- _
❑Entombment — — /
r Address
XCremation _; _0 17_ 0/_
Date Place Removed
ZZ ❑Removal and/or Held
2 and/or
Address
N Hold — — — —
O ' Date Point of
N ❑Transportation _ Shipment
G by Common i Destination
Carrier
❑Disinterment
Date Cemetery Address
Date I Cemetery Address
0 Reinterment
i
Permit Issued to Registration Number
Name of Funeral Home I-4ckynAt cl \l , &A.ker 1 LtnC r CLI t�orr rt- _'` I1 50-_
Address
1\ I-a cAyQ. H c -)A. , C L�r.en O k(V , tiE ,,1 --lot-L. 12 v'-j -
Name of Funeral Firm Making Disposition or to Whom
I_- Remains are Shipped, If Other than Above —
2 Address
0
w
O. Permission is hereby granted to dispose of the human remains descri ed ove s in a ed.
Date Issued ( ' /y 26/1--Registrar of Vital Statistics ` _
(signature)
District Number 5-60/ Place GAAV P clrC�
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
iZ Date of Disposition 1-►S-i1 Place of Disposition __ • ',,u 0cu..) fforti ._
2 (address)
W
N ---- - -
0 (section) � - (lot number) S (grave number)
Z Name of Sexton or Person in Charge of Premises _________ r 1 fC r l"'t�
(please pnnt)
W Signature __ Title GA,E.MArzDil
(over)
DOH-1555 (02/2004)