Albach, Margaret vHK STATE DEPARTMENT OF HEALTH , v, ".7
B rial - Tr n i rmit
.,rds Section l,l a S t �
.me First Middle ast Sex
c.
Date of Death Age If Veteran of U.S. Armed Forces,
D C{ _ /9
War or Dates
Place of Death A-
G Hospital, Institution or
City, Town or Village Street Address
Manner of Death �� Natural Cause Accident [�Homicide Suicide Undetermined Pending
I Circumstances Investigation
--,` Medical Certifier Name J��� rj� Title r
Occ t
•
Address J 44, et
i /)1, ,� ,r )U
Death Certificate Filed `� District Number Register umber /V
<< City,Town or Village 5 75o 0
OBurial Date } L� Cem tery or Crematory
r ! 7 i tlle.- 11 cQVJ Gr i
: O Entombment Ad Less � Si
><" V remation 1 Q u-it. Ro&r J 6 ik evs Jo ar Al , 2 deli
Date T Place Removed
Removal and/or Held
and/or Address
Hold
0° Date Point of
O Transportation Shipment
Ei by Common Destination
Carrier
0 Disinterment
Date Cemetery Address
: 'Q Reinterment
Date Cemetery Address
Permit Issued to Registration Number
c• Name of Funeral Home 601Yt lac..ys i G A 0:1"4p Fiki-, ( CCc ft- Uo-,3 Cy
Address `IO 2. ih/f A i/LQ- = J,c . 3Fi, 5""• Ai j / CC
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address •
ilk€
°:; Permission is hereby granted to dispose of the human remains described above as indicated.
iiiiii Date Issued 5/-1 11� Registrar of Vital Statistics 7 �cvlc/ n ..
(signature)
til District Number s7 So Place 0 j
<> I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
rfy !�
;%Lt! .v
Date of Disposition >�=��- Place of Disposition tH
(address)
La
(section) 1 (lot number (grave number)
LL 3iiniti
m,` Name of Sexton or Person i Charge of remises % (please print)
Signature G' ' L Title azt O -
(over)
DOH-1555 (02/2004) •