Tauschen, Martha 11 S 1-1
NEW YORK STATE DEPARTMENT OF.HEALTHL -`I
Vital Records Section ' Burial - Transit Permit
Name First AA Wd le Last Sex
TTAkc cH bv•---
M Date of Death/ Age If Veteran of U.S.Armed Forcps,
7 1 3 4 3 P- c, War or_Dates__
1.-- Placeltiri•-if HostIndz'sstitutiori`o , I/
CitY ' ' Villa9e 1—) (.f- cAliavi.A./\ Street )-7-- /Amu o,.. AL&W s C61
Man - ' '" t FA Natural Cause 0 Accident 0 Homicide 0 Suicide FlUndetermined n Pending
41 "'"Circu tances I—I Investigation
!Li Medical Certifier Name
a CtilL4,--` klIATO• Title
..... Address
37-)
MI Deareicate Filed itrict 41. Number
Town r Village r"7-- 6-:";b
DBurial Date
7/ --- //3 Cemetery Crematory /0
1 Aal 0'Vi &I-3
[]EntombmentAddr
ess
Cremation Q uez6_, ao 0 7 Af-7
Date Place Removed /
gi[]Removal and/or Held
Address
Int Hold
co Date Point of -,
In 0 Transportation Shipment
c i by Common Destination
Carrier
Disinterment
j El DisintermentDate Cemetery Address
ID Reinterment Date Cemetery Address
KT: Permit Issued to Registration Number
Oi Name of Funeral Home t-ialnard "D.Za)cer Fune cal Home 0 i II 0
i] Address S
I
10! I t a-rave-1-4e
" L i-r ee , Glace nsbur y i Ne NA.) v or- lc la 20t4
Name of Funeral Firm Making Disposition or to Whom
.E. Remains are Shipped, If Other than Above
Address
5
Permission is erebp granted to dispose of the human is describ abo as indi ed.
Fil Date Issued 7 ij" Registrar of Vital Statisti
signeiat/u e)
District Number5715 Place 1-- i-LL/CC/
igii.il c., 0
I certify that the remains of the decedent identified ve were disposed of in accordance with this permit on:
Z
ta Date of Disposition 1-11-11 Place of Disposition 'Pall)/V
(address)
111
LW
Ir (section) (grave number)
0
0 Name of Sexton or Pe n in Charge af remises til7tytupRurrer),NeasNit4-
2 02Idake P;int)
14 Ei Signature Title CIZE 1'40 t
..„...
•
(over)
DOH-1555 (02/2004)