Draper, Mary NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Ell Name First t 'I Ail I /! Middle -}�La P Sex
F
Date of Death 7 `� Aged If Veteran of U.S Armed Forces,
0(o 2-&- /'f Dt� War or Dates
14 Place eath Hospital, Institution or (�
W Ci Town Village O r � Street Address HQ/th Q C-rug � N
ci Manner of Deathlatural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
tu Medical Certifier . � J iT,j �
� J"4
5d is 4 e- tt>r,lz- et � /UV /
Death Certificate Filed District Number Register Number
City, Town or Village
<> ❑Burial Date Cemete rem t
['Entombmenteco--3 0 f / iP..s.2
Address
£4t n
Cremation 99f
Date Place Removed
Z Removal and/or Held
2❑and/or Address
P
Cl)
Hold
0 Date Point of
8"1=1 Transportation Shipment
0 by Common Destination
in Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
iiiiiPermit Issued to 'AA� �i��� �t ' Registration f�,��mber
Name of Funeral Home u't r 1
ioliiiii Address
13,E 1MA /,4 S1 , , Sc 1, > / )z'3
Olii Name of Funeral Firm Making Disposition or to Whom
14 Remains are Shipped, If Other than Above
Address
LEI
Permission is hereby granted to dispose of the human re sins described above as indicated.
iia Date Issued O(p, 2p1(--( Registrar of Vital Statistics ,/ cZa/k—e--
(signature)
li District Number 4%'2, Place7-#110Rkpft; p-/.
;: I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
)
W. Date of Disposition 1'3-111 Place of Disposition FA ✓ Crt aI#•.,
2 (address)
Ili
to
cc (section) A (sot number) (grave number)
('
Name of Sexton or Perso - C arge of Premises o.) as 8
(p e print)
Signature v24" Title COV6Y(04
(over)
DOH-1555 (02/2004)