Duffy, Shirley -
"
NEW YORK STATE DEPARTMENT [}FHEALTh t# ~
��U8�^��8 ~ 7��%aR���U� ��*��O��~�
V/t�| RenordnSeodon 0�o°~. U~~n Transit n- °~. ...nu
Name First Middle Lost be
� �� �'� �
Date of [>ea�6_'/ Ae-� |f Veteran ofU.S. Armed Forces,
War orDates
Place of Death ^ Hospital, Institution or
Village
Street Address ���. -/
W1 Death Na�uod {�auxe �-lAo �den� ��Homioide Suicide F-lUnde�ermined El Pending
�-� �� ����inounnstanoeo �-^(nvendgadon
MedicalCertifier Name /Title
Address
� ��� ���~� m
� J�
^� � ^° ��� «
Death {�artifivateFiled - ' -Bx�r(tNu m-ber 'y Register Number
0� Qty, ow" orVU\age "�x*,,�' ^�����/�~��
Date ' ` Cemetery or Crematory
El
- - _-~-_
Addresu
... remation- \ Date Place Removed
[-lRemoval and/or Held
^-~and/or Address
Hold
Oo10 Point of
�-7Transportation Shipment
by Common Destination
Carrier
Date | Cemetery Address
\Disinterment
Date Cemetery Address
/Rentermont
Number
Pern�hIssued to Registration
Name of Funeral Home
Address
Name of Funeral-firm Mak'Kd Crisposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human ain descri4e4 abo as indicated.
Date Issued Registrar of Vital Statisti V,
Place
;7
| certify that the remains of the decedent identified���ovewooe disposed of in accordance with this permit on:
Date of Disposition '-3 Place of DispositionUJ
4��
mi
(section) b (grave number)
Nam arge of Premises _-�/*�� »�m°u �" �^q��
(please print)
-'�� °�_.��
Sign ��~~ Tide � } �r°"^/1.'�x~��^
^^\_�
�
OOH'1555 (10/89) p. 1 of 2 VS'61