Macey, Dawn NEW YORK STATE DEPARTMENT OF HEALTH * k /r 7 )Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Zia..� r' Y1a+h 1ee.n N.acey F
Date of Death O7 12-31 2-61�{ Age q O If Veteran of U.S.Armed Forces, N O
. War or Dates
Place of Death Hospital, Institution or
City or Village Qt�elnS cl Street Address W oUY A- I roe;I ;�(
Manner of DeathaNatural Cause 0 Accident 0 Homicide ❑Suicide ❑Undetermined �Pending
:$ Circumstances Investigation
Medical Certifier Name Title
ill
12o51. h r1 fir• \or MD
Address `
;,. i NI i2
Death Ce 'rcate Filed District Number y R ister Number
`, City ? Village G U1eenS r-1 -S1 0,C
ElZ� 201`\Date ` Cemetery or Crematory
t Burial 01 l Q,In e.V i ew Cr erna4
Address
®Cremation Q..„aVI er Q- a CD 0-Qs2x13131•Ary I N.y.
Date Place Removed
a❑Removal and/or Held
.. and/or Address
', Hold
6 Date Point of
.`• 0 Transportation Shipment
ary by Common Destination
Carrier
Q Disinterment Date Cemetery Address
:.Q Renterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home/avnard b. &Liter Fwierc'-f me- oil 30
Address i1 LCQ i2.ti e (51-• , 0 tAlC.l in bt-t-rV r )(JUL) L/044- 1 a SQL
Name of Funeral Firm Making Disposition or to Whom
': Remains are Shipped, If Other than Above
5:. Address
.z
Permission is hereby granted to dispose of the human r ains described above as indicated.
Date Issued-1)Z-y'c�C..)t ti Registrar of Vital Statistics Q. CI 0- •�
(signature)
District Number Cs Place 1 ��--Es"- CUE-'
. L
I certify that the remains of the decedent identified above were disposed of in,a e with this permit on:
t Date of Disposition? .5 Place of Disposition At Li/.A./ rd6
X (address)
w
IA
CC (section) (lot umbe`) (grave number)
flName of Sexton o son i ge Premises e.4 d
g (please print)
: Signature Title (� /
(over)
DOH-1555 (9/98)