McConnell, Mary NEW YORK STATE DEPARTMENT OF HEALTH A 33
Vital Records Section Burial - Transit Permit
1 NameF,li.,
idle Las,; Sex
Ni Date of Death
// 6 �f3 Age If Veteran of U.S. Armed Forces,
( - 72 War or Dates
a Place of 0- •th Hospital, Institution or � n�
City," ,,r Village Street Address .- e tee...
ci Mann- . Death Undetermined Pending
Deathly.Natural Cause �Accident 0 Homicide 0 Suicide 0 �
IN Circumstances Investigation
Medical Certifier Name &Let "7"--*
i ddress
••••• /0 7-- '"Q.A-- /N:&---
),Pfre C9.446 /0/
iii Deat e - icate Filed District Number Re iste Number
iiij� 9
<:>: Ci To or Village Q,_-/ ���If
Date j Cem ry or Cr matory ry
--.�
El Burial la - b—/3 re .Let.ii
Address
Date Place Removed
0❑Removal and/or Held
. and/orliT; Address
a Hold
9. Date Point of
iti Q Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
i PermitameIssued to � 2. 4•dre Regis0tiq . um®r
"'� Name of Funeral Home � //'
Address GI/ /� /� 11
4-67944 '
>.:i Name of Funeral Firm Making Disposition or to om
12 Remains are Shipped, If Other than Above Q9 ' PM R•�i
I Address `�
M
Permission is hereby granted to dispose of the human re ns described above a dicate .
<> Date Issued ‘-‘-/3 Registrar of Vital Statistics //V
(signa6)
III District Number 7 Place / ).__ 2
I certify that the remains of the decedent identified above were disposed of in ccordance with this permit on:
Date of Disposition b" 1013 Place of Disposition ,*t11.,s, 6�4[tog—
a (address)
ILI
U)
G (section)
(lot 'm r)/ .__S‘ (grave number)
Name of Sexton or Pers in Charge of remises Ai (er ter{
z (please print)
W Signature Title nail kZT)l2.
(over)
DOH-1555 (9/98)