Mosher, Mary NEW YORK STATE DEPARTMENT OF HEALTH . (03
Vital Records Section Burial - Transit Permit
giiii Name First Middle Last Sex
>> Date�of1Death Age If Veteran of U.S. Armed
gForces,
act • \ - \\. S 5 War or Dates
ig Place of Death Hospital, Institution or
City, Town or Village 1 1-,:v 2e f y`1& Street Address I i Jh K s
Manner of Death Natural Cause El Accident ❑Homicide 0 Suicide ri Undetermined ❑Pending
flCircumstances Investigation
ul Medical Certifier Nam Title
asu. in-p
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`a Dea a ficate Filed District Number 5 1 Register Number
Ci�or Village p
zl f^2�_ b ((�o
Date r Cemetery or Crema
❑Burial /J / v i r :n-e V;c..� 17J'e
Address � !
®Cremation /)
FDate Place Removed
2❑Removal and/or Held
ii and/or Address
O Hold
O Date Point of
al IDTransportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
>< Permit Issued to Registration )umber
iiiiiiii Name of Funeral Home p�'15 2�)Y2 ���'�' r7z e Ov '�
Address
, e2/91A-j /i vei aemv-L., ,/uy. /,)s:2, )--
�_' . Name of Funeral Firm Making Disposition or to Whom
valiC Remains are Shipped, If Other than Above
Address
al
a Permission is hereby granted to dispose of the human r ins describ d abov a indicated.
giiii Date Issued j)7 -/7- / Registrar of Vital Statistics �=�.- (-,4-e-tJ-
si9 ture °
)
iiilili District Number VCaJCo Place La-& /C/LP//G-/2-e. AJY / %(7/ ,
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
6 Date of Disposition 2114 Ov Place of Disposition ,,ram C-r too,
;; (address)
LU
U)
ft (section) J(lot umber (grave number)
GName of Sexton or Person in Charge of Premises i,, . ,MAr
g diaL
(please print) ppt0 Signature Title a -�4
(over)
DOH-1555 (9/98)