Mabb, Katrine EW YORK STATE DEPARTMENT OF HEALTH
ital Records Section Burial - Transit Permit
Name First i i Middle Last Sex
la /a\ I ao 1", �
Date of Death Ag I If Veteran of U.S. Armed Forces,
� or Dates
Place of Death Hospitwaral, Institution er
City, Town or Village Qv ti e �S�jv r Street Address " V e r'rI b k A� e.-
Manner of Death®Natural Cause Accident Homicide 0 Suicide Undetermined 0 Pending
Circumstances Investigation
Medical Certifier Name 1rv‘ Title
Addres° �.,
Death cam- ate Filed --gyp District Number Register Number
City, o � Village �„� �S ��a
DateC/ ' C metery or rematory
❑Burial �a /a 3 �oZd I ti=1J� T-t Vi CI?C M ATO Q`-t
Address
Cremation QoAY R. IZ-1) Qv r✓E.P--)5 C3u Q.`i NY-t (� 6y
Date f'f Place Removed 1
El Removal 1 and/or Held
and/or Address
Hold
Date --- -T Point of
Transportation j Shipment
by Common Destination
Carrier
Date Cemetery Address
Disinterment
Date Cemetery Address
Renterment
Permit Issued to Maynard Registration Number
Name of Funeral Home 1�a ynarC� ker �c�c ner� me- i Of I 0
li Address II Lara-L/F,ttC (+. , &ciceLnsbur ; /(Jew Lkrle- l a'U`-
..:.
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
AddressAIM
2e�: dispose of the human r •escrtbe'\- in icated.
Permission is hereby granted to �� '
_�i�Registrar of Vital Statistics •
Date Issued 1 ature)
,-,--
1--i Place %D(� C �'`'' y"
District Number 6jl�S 4.ance with this permit on:
decedent identified abov- were disposed of in
�: I certify
that the remains of the f r4...) •4 ni -
Date of Disp��0n I L
Place of Disposition (address)
(section)
of num ) (grave number)
•
or Pers
Title+• inCharge/o Premises (please print)
s of Sexton its
Name (over)
a `
Signature
'