Donnelly, Esther NEW YORK STATE DEPARTMENT OF HEALTH ` ) it s--L3
Vital Records Section Burial - Transit Permit
mi Name First Middle Last Sex
.ES' T/1ER S OD1./NEL/Y f2322,9A6-
4iii Date of De th Age ' If Veteran of U.S. Armed Forces,
Mii /W OI.V4 O /V 7YRs: War or Dates A/ Q .
44 Place of Death Hospital, Institution or
City, ow or Village ki 6s'8 it d?y Street Address /3 4 Roe K e/Ty , 0•
1Manner of Death N Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ri❑Pending
1 M1� Circumstances Investigation
Medical Certifier Name Title
4 ANrfloA/y 7 7/9CcA ma- _
Address
-re 0A/ &P7 c7R, 611h/S / h/-S ivy /2d3-4 ' /
Death Certificate Filed • District Number Register N mber
s> (Mar•rVillage /�//�/as/straJ/ 3-7$ .2 /.&
Date Cemetery or Crematory ,
❑Burial /OfrIg%0/1 eP/A/E0a,e1 d Riz3,119 lee/a/ri
Cremation Address r ` /4do f/
/.�EE.vs rt3G��� 7�
Fate Place Removed
g❑Removal and/or Held
and/or Address
a Hold
Q Date Point of
It❑Transportation Shipment
B by Common Destination
Carrier
Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
'I. Permit Issued to Registration Number
'<° Name of Funeral Home jy) /t S'Q/J FUX/�7,4 Z. He ?74' e'/// 7
I€ Addr ss
cs . C�30X4 `72 Fc1R7T13N'/f Ny ,/ �� 7
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
iiiiii
'< Date Issued /O/-. 0..0 Registrar of Vital Statistics Y, .,_ 2 o.�c j--0
� -'L—
(sig ture)
District Number -S7 Place TBI.!/A/4 le.N/<//1(ASte iii? thy.
I certify that the remains of the decedent identified above were disposed of" accordance with this permit on:
f- Date of Disposition 101411Z Place of Disposition r+.�UcL CrfAilor t`"'
2 (address)
LU
IA
(section) lot numb fn (grave number)
GName of Sexton or Person i Charge of Premises r t•Ivli
g (please print) /�y�
Signature Title (te r014/7U't,
(over)
DOH-1555 (9/98)