Meehan, Tracy NEW YORK STATE DEPARTMENT OF HEAD H
Vital Records Section Burial - Transit Permit
Name Fit Middle Last Sex
—Tra.C y _14 p-e-e-I i n 0 -F.outtQ .
Date of Death If Veteran of U.S. Armed Forces,
—I (.75
-2.013 War or Dates N o
t'"i Place of Death r Hospital, Institution or
u4
City, Town or Village l l t'' Lax Street Address M Y-CA L�.t tJi r i ayil r
0 Manner of Death li Naturdl cause 0 Accident 0 Homicide Suicide �Undetermi d Pending
itiCircumstances Investigation
. Medical Certifier � Nam1r�� Title
it'd Y i q cl_._ �b
ress
1 k a.0 4 .der-4- /(.L - La i 'Y
Death Certificate Filed �" District Number Register Number
City, Town or Village
1,s2) g
['Burial Date C etery r Crem tory -
['Entombment Add 6// "kp/3 rt n.e ( ! � 11!'f Y�CL 30 ty
! > Cremation �0 c:Cr15 bt2 NY
Date Place Removed
Removal and/or Held
and/orHold Address
0 Date Point of
Transportation❑ p Shipment
E by Common Destination
Carrier
❑Disinterment Date Cemetery Address
•
tii❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home t jam- ;l e_r ' O i�act
Address [[11
C�357 3o iod cuic L 'y l Z yZ
Name of Funeral Firm Making Disposition or to Whom ,
Remains are Shipped, if Other than Above
Address
2
in
PI Permission is h reb granted to dispose of the human re a' described above a in scated. i
Date Issued 3 15 ao 0 Registrar of Vital Statistics �f. ( ( ( (( ( -r . , t .7(t ,
signature)
District Number jb S_ Place /U IZ a
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Lu Date of Disposition --/�-73 Place of Disposition Awe V„A/ O 4/34..i/
t2 (address)
ta
t (section) (lot number) (grave number)
0
Name of Sexton r Pe n in ge of Premises L ) -o- a
2 (please print)
i Signature Title i,1 D‹ 43-4:
(over)
DOH-1555 (02/2004)