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Whitty, Mary NEW YORK STATE DEPARTMENT OF HEALTH it LP 3 Vital Records Section Burial - Transit Permit Name First 4adle Last Sex MAr1 e- 4JL) Tr A1,1.t._ Date of Death Age If Veteran of U.S. Armed Forces, id '`� s i-s r t a o 13 'J-5-- War or Dates 1'J 0 Place of Death Hospital, Institution or City, Town or Village S root--1 Street Address / . / 0S i i 10 i Manner of Death Natural Cause 0 Accident Homicide Suicide Undetermined Pending t Circumstances Investigation ill Medical Certifier Name Title 41. ,T o-setJ , Sc/t W et-nj pA, 1)'1 D Address / ailil SG4j I-V L 1\A4. F eA' , �j Ier S t.�'! 1-01511/43 llj4.-- t)'. j a-ev Death Certificate Filed District Number Register N tuber City, Town or Village 3c-4 y-OCc A (%03 ❑Burial Date CemetAy or Crematory Os` ©a - 34 L3 rih;Q.Oa tat, er 43 7„-,./ ::: .❑Entombment Address 111 Cremation Q0eeas LurI, IkLy' Date Place Removed Z El Removal and/or Held and/or Address I Hold 0 Date Point of 0 Transportation Shipment G by Common Destination Carrier Disinterment Date Cemetery Address ME 0Reinterment Date Cemetery Address Permit Issued to { � Registration Number Name of Funeral Home gd ujp L. �6t' rU�I1erA( /'jd/JQ— OaCi7 ;;; Address & rOrn 4.AA- /u/, / (P'76 _ < Name of Funeral Firm Making Disposition or to Whom # Remains are Shipped, If Other than Above _ 2 Address CC Ili f` Permission is hereby granted to dispose of the human sins described above as indicated. `Date Issued O8-a/- deL3 Registrar of Vital Statistics Cc, /1.h ,t.,,t_)c(A.,._e_ s. ignature) District Number 1-510 3 Place SC4119/0 11J , I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: 1-. Z Date of Disposition g f Z((3 Place of Disposition i...0 %., CR,rc'1"o(rv� (address) tLJ U, ix (section) glot number) (grave number) ta Name of Sexton or Person - Charge of Prem. es s 2w•, { Z (plea a print) 44 Signature Title CI1gMrSwZ (over) DOH-1555 (02/2004)