Daly, Carolyn NEW YORK STATE DEPARTMENT OF HEALTH r ',4 I' LaVital Records Section Burial - Transit Permit
Name First A I D Ly N Middle s Last O A L y Sex F
Date of DeathOq I oZ� , a O 1 Age I If Veteran of U.S. Armed Forces,
War or Dates
S. Place of Death Hospital, Institution or F U LT 0 N CENTER FOR
7 City, Town or Village TOf NS TOwn, N' Street Address REHA B I LITRT 4(onHEA1.h1'1 CI}2E
' Manner of Death Natural Cause Accident Homicide Suicide Undetermined Pending
fif Circumstances Investigation
U.
idi Medical Certifier Name Title
JEEP FtcANo MEDICPL DOCTOR
Address
841 COUNTS H 1H (aa, &tOVEQ VIL -6, NNI
Death Certificate Filed_ District Number Register Number
gij City, Town or Village JohnSto /7L5 S/
Burial Date ol I aq I A o l 4 Cemetery or Crematory
;>❑Entombment Pine Vtc CreM ft-ro e•1
d Address Queen3 Del, t'4 N '4 ofz
Cremation
Date Place Removed
gEl Removal and/or Held
and/or Address
t= Hold
0
0 Date Point of
Transportation Shipment
Gi by Common Destination
Carrier
Disinterment Date Cemetery Address
3 Reinterment Date Cemetery Address
Permit Issued to Registration Number
j Name of Funeral Home S mg Ie,tON SOU.A v Riv purr e ruCK.QA1 bflie 0159 is
Address 401 6 1,1-r I R( , ouem BU i y , New \1 0 12 K 1 a6O4
Name of Funeral Firm Making Disposition or to Whom
#, Remains are Shipped, If Other than Above
M Address
Permission is herebygranted to dispose of the human remai s d cribed ab ndicated.
p � _
Date Issued 92...9J2oJ '/Registrar of Vital Statistics12471'`3 si nature
( 9 )
District Number /7Sy Place -��,n�- ¢11
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
>U Date of Disposition io Ii lay Place of Disposition gcUicw ar-cturt;u.--
(address)
Lu
44
CC (section) (lot number)_ (grave number)
jti Name of Sexton or Person jn Char a of Premises d «s#: ' Je n 4
``� (plelase print)
El Signature L L� Title Gift oimitn
(over)
DOH-1555 (02/2004)