Marcio, Margaret NEW YORK STATE DEPARTMENT OF HEAL1 l-1 �g
Vital Records Section Burial - Transit Permit
Name First M" le Last Sex
Mt rgo,r e} M arc,U F
- Date of Death Age If Veteran of U.S. Armed For ,
12- lb C 13 27 War or Dates Ave
P ce of Death 2ess
Ge(S Ca 11 S ee G it (`e \ �C 0.S p-I+A 1
< Manner of Death ff Natural Cause DAccident Q Homicide 0 Suicide n Undetermined Pending
Circumstances Investigation
t Medical Certifier Name Title t,U�
J+2 Gc C C.
%6 C-L/.Jc E'l/� /` ►.J
Address
"
J I & / tart, Q g7) /U/ l 2,,red 4
' ;, Certificate FledDistrict Number R er Nu ber
/`
> ,, Town or Village L '�,13 il'LLS 5(Co
<
Date , /9 i
�i Cemetery or Crematoryrk
: ,Burial ►n v,�v3 C
O em0.At}f y
Address
:: ; Cremation QVAree ,iy i I1 t2 LJ
Date Place Removed
0❑Removal and/or Held
F.! and/or Address -.---
a Hold
Date Point of
Q Transportation Shipment
8 by Common Destination
Carrier
Disinterment Date Cemetery Address:El
0 Renterment Date Cemetery Address
4' Permit Issued to y Registration Number
Name of Funeral Home Haynard v. ctic �ur�e�c� Horne_ QI 130
Address i, Lai
a-yRate af. , 6(A.0 OWL -nd 1 Aie w /ors 1ae01
Name of Funeral Firm Makin
g ng Disposition or to Whom
$1 Remains are Shipped, If Other than Above
Address
!:-.k
k Permission is hereby granted to dispose of the human remains described above as indicated.
.,. Date Issued i2/191/2 Registrar of Vital Statistics ('cx..,` S2 L )
(signature)
District Number gi3/ Place 6 G''�S C (S p A1 L
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
f
iti Date of Disposition (a 1)31(3 Place of Disposition &.L. VuW Ctr foC w
i (address)
IA
2 CC (section) fit number) (� (grave number)
Name of Sexton or Perso in Charge of Premises r,1 ✓ D of
(please print)
Signature Title C,KitVirie
(over)
DOH-1555 (9/98)