Mullane, William A.i6'a
NEW YORK STATE DEPARTMENT OF HEIALTHr Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Di t l I�__ z J c.�,�cr-� 01 LI 1sQ
Date o Death A.- If Veteran of U.S. Armed Forces,
0 .wAr 1 a War or Dates •r .
14.• Place - a-:h Hospital, Institution or
ZCit , Town o illageL Street Address
it/
Man - of Death Natural Cause ccid nt 0 Homicide Suicide Undetermined 0 Pending
Circumstances Investigation
Medical Certifier Name T e (�
0 al
rt4 6(GC. ,D
Addretsc�
Der rti to Fir District Number Re ister Number
Citn rile
¶C '] '3 ( -)
❑Burial Date Cemetery or Crein�tory
-ate/ 3 A'%7 e V, e 1,✓ Ge. � f
❑Entombment Address: / A // y
�- .`Cremation 67�c,1-°--�' G W., t ee.i1, I� IA IA,/ / ,�///j" A? a
Date Place Removed„ J
Z Removal and/or Held
❑and/or
;; Address
Hold
to
0 Date Point of
n"0 Transportation Shipment
i by Common Destination
in Carrier
Q Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home /Vi4 yr) 04 R A I?fq ---f4R. o I I>v
Address 1 y a
Name of Funeral Firm Making Disposition or to Whom T
li . Remains are Shipped, If Other than Above
Address
0
1
` Permission i hereby granted to dispose of the human ains described abov as indicated.
Date Issue 0.-c)-'( l Registrar of Vital Statistics Q, C
(signature)
District Numb Place )6 ,_,-, .5-(' OLA...„2_12 .n
` I certify that the remains of the decedent identified above were disposed of in acco ance with t s permit on:
III iz
Date of Disposition 3-ZZ�3 Place of Disposition ' .i' _ 1 t inv.- ,e'
2 (address)
0
C (section) lot nuber) v (grave number)
fiti Name of Sext rson in Charge of Premises tfjJ' /W\
(please print)
ft: Signature / " �/ Title
(over)
DOH-1555 (02/2004)