Fish, Mabel . * * # ( 11_
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle j Last . Sex
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'Ud Date of Death ! Age r, ' If Veteran of U.S. Armed Forces, ,
War or Dates )'1k.;
Place,o eath I
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Hospital, Institutio ___. ,
Z City. Tow or Village ci-ka.4-4u..A_, 1 Street Address Uoit./C , /AA , c! f tiv, i/ .
tManner of Death fJ Natural Cause Accident E]Homicide El Suicide Ei Undetermin d ri Pending
Circumstances 'Investigation
'II Medical Certifier Name f Title
ss
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Death Certificate FiledDistrict Number - — ! Register Nucnber
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City(To or Village Qiy
Date LI J Cemetery or Crematory
!!!' 0 Burial i 0,3 - )6, -/,), '._) 1.11--e V Le.i.Z e JD-1_
Address
•,''' NCremation i CAP.o "-a 6 6.c,t )1,c/ 17 tet,__
Date ._j PlacefRemoved
ZRemoval : ' and/or Held
0 o
and/or Address
g Hold
9 ' Date ! Point of
El Transportation ! ! Shipment
ci by Common ' Destination
Carrier
Disinterment Date ! Cemetery Address
Reinterment Date i Cemetery Address
:'•-- El , .
Permit Issued to -1.1 i i i ' Registration Number
Name of Funeral Home /k LA_.,tt...6.,/t )Lc.A__E,...*_&... /7x..e._ ' 0// ?
Address
Q 30 ViL4_0,c4L._ Zdt,!t_t )1-:y- id (a
Name of Funeral Firm Making Disposition or to Whom
1 Remains are Shipped. If Other than Above
Address
Permission is h/ereb cglranted to dispose of the human remps2r(i.bed eh°,s indicated.
Date Issued 3 ace, r Registrar of Vital Statistics
„:,
(signature)
District Number ,c4i.cs Place /0/.2.)11 Of a-1)P,S&if ../'
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':. I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
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2 V _1
Z Date of Disposition 3-11-a Place of Disposition
111 [ ,...t, it, Curet r.0 ok.,
2 (address)
tii
th
CD (section) A, (jot number) c (grave number)
° Name of Sexton or Person in Charge of Premises
13 i A,A.t.p iv e 3 volt
z (please print) i
44 Signature Al— 4--s- Title eVii.hirt"(A-,
DOH-1555 (10/89) p. 1 of 2 VS-61