McDonald, Patricia NEW YORK STATE DEPARTMENT OF HEALTH ��
Vital Records Section Burial - Transit Permit
Name First Middle M st Sex
�A ki'C 1 �. / '/L + CJ�ia�4 roc A%e..
igi Date of Death Age If Veteran of U.S. Armed Forces,
- a - 9,013 C 7 War or Dates NQ/U€-
Place of Death Hospital, Institution or "
City, Town or Village /�J�'NeY✓AA Street Address ti'c'rih �dods «"6 i&,,qd
• Manner of DeathNatural Cause Accident Homicide Suicide
❑ Undetermined �Pending
Circumstances Investigation
fj Etii Medical Certifier me- Title
L /^4-AVL/S (?A H7o. _C
I T Address ici
&.,,, 16 r IAIAlp 4_ 19bi a dr Ny. / .2 ? ,./ (
iw
wi Death C fficate Filed District N gr Register Nr.�nber
Riiii City, own Village itiervA ,/
Date Cialletery or Crertiator
❑Burial 0 A - / 8 ),d l.3 PI NG, VI W rP,. ra 7 fr '
�'�( Address 'J ff
i�iCiremation 4',i {'�2 �11-- t/e.e_N.3 6 ()Vy. '
Date Place Removed
g ❑Removal and/or Held
and/or Address
a. Hold
Q Date Point of
Si Q Transportation _ Shipment
C by Common. Destination
Carrier
El Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
iNil Permit Issued to lyy►- AS. p{,irne.i- route', t Hor1.e_ Registration Number OM 9S
Name of Funeral Home .62
Address ! ; , A-4 A., S''T. moo `ht. 6 t-r r . J Z
lim " "r L a Ai to --_) -
Name of Funeral Firm Making Disposition or to Whom
'" Remains are Shipped, If Other than Above
s Address
11
iiiI Permission is hereby ranted to dispose of the human remains described above as indicated.
Mi
Miii Date Issued eA !� ' Regis rar of Vital Statistics
iiIii (signature)
District Number i.S-Sl/ Place (,-t,,Q Y li A iu r e
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: •
v L� s��
W Z
Date of Disposition - '?0 Place of Disposition ,fs ru,�
2 (address)
1L I
ti)
C (section) Aft number) (grave number)
0 Name of Sexton or Person in Charge of Pr mises rrr nrli
(please print)
W Signature4L-- Title C
• (over)
DOH-1555 (9/98)