Haux, Mary 11-9(11
NEW YORK STATE DEPARTMENT OF HEALI`t-I
Vital Records Section Burial - Transit Permit
Name First kA Middle Last Sex
ari -;Zubt 14ctuX _ F
Date of Death Z Age If Veteran of U.S. Armed Forces, - v
OZ'CU)- O1'1 i q ?j War or Dates IQ ) A
1-. P e of Death Hospital, Institution or
City,Town or Village G)t,n S rct 11 S Street Address G tims 1\S s , +l —
a Manner of Death RNatural Cause 0 Accident El Homicide 0 Suicide ❑Undetermined Pending
ILI Circumstances Investigation
Lint Medical Certifier Name Title
Q
Address
\ 'clr\t- S & nsc S , d .y 1-z 3Q1
Death Certificate Filed District Number Register Number
City, Town or Village G lens �ql\S ��� `
❑Burial Date Cemetery or Crematory
oz i v 20 -Pi one_ V;c C,•ar a. ry
❑EntombmentI Address
[;Cremation I _u V ' AI 1 Z$u -- __
Date Place Removed -!
Z Removal _ and/or Held
Q❑and/or I Address
Cl) Hold
00 I Date Point of
tt Q Transportation Shipment
O by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address -
Permit Issued to - 1 Registration Number
Name of Funeral Home Hay►al C� D. [�( kt' F (-gi)t', C; I '-,0,1
Address
11 La-fa VC-} -tc_ c-lr ( ( A ) C c.tcci i i-i)tt i k/ , t\:'(- ,,` yc,; j< L ( ), i
Name of Funeral Firm Making Disposition or to Whom
1 Remains are Shipped, If Other than Above
Z. Address
tC
Ili! - --- —
0." Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 21!D / r LiRegistrar of Vital Statistics LA, �w
(signatur
District Number 5601 Place 6 CQ
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Ul Date of Disposition 4/11 114 Place of Disposition _ tru �r� TCC/U�,
r�
(address)
Ili
to
CC (section) (lot number (grave number)
pName of Sexton or Person in Charge of Premises _ l_hr�+ e , „ 0
Z (ease print)
ICJ Signature _ _.- Title cRl ►ti]
(over)
DOH-1555 (02/2004)