Waghorn, Mary \ 4
NEW YORK STATE DEPARTMENT OF HEALTH ° �� I
Vital Records Section Burial - Transit Permit
Name „First gZe re4Mi I� ,Ly�st tcfer2s,
S`I�G •:2_Date of Dea Age If Veteran of U.S. Arrr€d
Q `Jr /�D/c /3 �p' 5- War or Dates
j-: Place of Bath Hospital, Institution c /, /� /
X City, Town or ' ;.- r rgiivi C(€ Street Address �_L-rn/Q{2 /elve rlVur.c, -
Manner of Death Natural Cause ❑Accident ❑Homicide ❑Suicide ri❑Undetermined ending
IliCircumstances Investigation
tu Medical Certifier
erry RI
Addre J
/7 /� S� T'
Death Certificate Filed , District Number Register Number
City, Town or Village brow v l/t° �r7075- /
❑Burial Date jnetery r Crematory
['Entombment057 Vol /-3 'Pr/ ale l//�ece.l 9/
Address ^ ' �/
Cremation qu_p_,,ftsbctiry . /V /
Date / Place Removed
Removal and/or Held
❑
i= a Hnd/ldor Address
tO o
O Date Point of
0`' El Transportation Shipment
O by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
iiiiai Permit Issued to Registration Number
Name of Funeral Home At. ,lard , -deer' ®//30
Address
/7 id flye 6 .e_e�s b(A l, N 04aName of Funeral FiMaking Disposition or to horn
Remains are Shipped, If Other than Above
2 Address
c
tr
P.` Permission is hereby granted to dispose of the human remain descri d abov as indicated.
J Date Issued 4577 /3 Registrar of Vital Statistics
(signature)
District Number 6-7 5 Place 6ri ii ili f, iv i
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI Date of Disposition 57,2 c)-3 Place of Disposition / v'L L t/'mac/ agereti jagy
(address)ta
ta
cc (section) (lot number) (grave number)
ci Name of Sext o P rs in Ch rge of Premises CI
Z (please print
Signatur Title CleiCAPP514e i.- / r
(over)
DOH-1555 (02/2004)