Monroe, Jeanne NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial _ Transit Permit
Name—First Middle Last Sex
,J e et n ry MCL I1€. M 0✓1 rot— _ Ritual.
Date of eath Age If Veteran of U.S. Armed Forces,
3- D\ 1 S War or Dates No
}.; ; lace of Bath C j Hospital, Institution or
Town or VillageSCU id cos Sp`'1 Ac5 k Street Address I ('a c& h it-
Manner of Death 12kNatural Caus' 01 ccidenn 0 Homicide Suicide ndetermi ed Pending
Circumstances Investigation
11 MedicalCertifier Name Title
CI Ic.ice,, 1 Svkyr ► cct ikh
ddress
Death Certificate Fil c^ District Number -Register Numbe
City, Town or Village � �L_ ja r 1 5 1 �5(� ( Fig
Date ' CAmetery\or Crematory
❑Burial 1-2 ` 2-0 13 Y i (\t Y i c Lc.) 0 nick tt_"
Addr
Cremation] UU Ce.A-5 b
. 31
Date Place Removed
Z Removal ' ! and/or Held
and/or Address
CO Hold
9 Date Point of -"
NQ Transportation Shipment
0 by Common Destination
_ Carrier
Date Cemetery Address
El Disinterment•
Reinterment Date Cemetery Address
Permit Issued to i Registration Number
Name of Funeral Home N0 re u)w kA r�e ra \ Yw I n L 006. U ,
Address .4 b\a-r-c.h si` .kc tutz,e_ u .K (2, -1
Name of Funeral Firm Making Disposition or to Whom
-• Remains are Shipped. If Other than Above
- Address
Permission is hereby granted to dispose of the human remit' d ab' e as indicated.
Date Issued / P//2O/3 Registrar of Vital Statistics crivy) t - qtriairy k
/ (signature)
District Number 7 J�/ Place SARATOGA SPRINGS
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
F
WDate of Disposition I-3 13 Place of Disposition Ki.i 4,0,1 CI-614w,v 0--
2 (address)
w
(section) A
(lot number) (grave number)
Name of Sexton or Person in Charge of Premises r,yit /nie
(pleaseCi
print)
W Signature iL. Title I'MAW0.-
DOH-1555 (10/89) p. 1 of 2 VS-61