Carroll, Margaret NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name _First �� Middle Last Sex
IF araT. Oar-roil A9LiO _ _
Date of Death Age If Veteran of U.S. Armed Forces,
t D—D3—I 4 G, War or Dates y`,p
tN Place • Death Hospital, Institution or `' p^' � _ -f �^ �
Cit Tow or Village p (��� Street Address T,v( OP X C '17i
• Manner of Death Undetermined Pending
®Natural Cause �Accident �Homicide �Suicide
Ui Circumstances Investigation
W Medical Certifie Nam Title
kncto Auer C P
ddress
Ouce(\Sbo , f�
Deat -rtificate Filed District Number I Register N ber
City, • r •r Village mobs,(, 44,5(p a D
❑Burial Date __JCemetery r Crem ory
❑Entombment I 0P.3( (4 [ t ne- 1i(0Addre
remation Ul Idlt-t(1 U Tj
Date _) Place Removed
'Z ❑Removal and/or Held
and/or Address
Cl)
Hold
O Date Point of
440
Transportation Shipment
a by Common Destination
Carrier
. ElDisinterment Date Cemetery Address
Q Renterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home ►v l t 1\e - crurn +M€, 0109
q9
AddressUn7 a E-+ 30 ( rld10 Lcuici 1 J igtla
Name of Funeral Firm Making Disposition or to Whom
I- Remains are Shipped, If Other than Above
• Address
1r
LEA
• Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/ Z3`)y Registrar of Vital Statistics 9--
1` )t )u
signature)
ite—
District Number j..1S1Z Place 351 t2Ey N 0 L I?5 RD. i For £ du), Ni /
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
• Date of Disposition /o/ZN//'{ Place of Disposition ,rµ;V�,,, . Ed
I t+ fit....
(address)
to
CC (section) (lof number) (grave number)
CI Name of Sexton or Person in Charge of Premises - 4 St k et
2 (plbase print)
111 Signature �-- Title
(over)
DOH-1555 (02/2004)