Doyle-Cutter, Mary NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First �- a Middle Last Sex
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Date of Death`� Age If Veteran of U.S. rmed Forces,
5 to`_-3 ��
Al War or Dates .[(�
Place o th' Hospital, Institutio r
Ei City(�`fown r Villages Street Address
O Manner of Death n• Natural Cause ❑Accident ❑Homicide El Suicide ❑Undetermined ❑Pending
al `mil Circumstances Investigation
Cil
til Medical Certifier Name J Title
Address (,G�, e 3 �j
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Death --.ficate Filed District Number Register Number
City,( own it.Village \AA_„t k. .:1__ if/0/ 575_
❑Burial Date Cemetery or Crematoa .
: 0Entombment )1L7 b -C 2_{( '`��
Addr s
',Cremation 0 cuze-oLa
Date Place Removed d
Z Removal and/or Held
2 ❑and/or Address
E: Hold
U.)
O Date Point of
tEll Transportation Shipment
O by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address •
Permit Issued to - Registration Number
Name of Funeral Home CSC. --fix)-. • Go fey
Address
C t,Lii- ' r°dQ 6 r 7 apt , Fit.. (1 , / 3 ,
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
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` Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued /i f(o'.70/� Registrar of Vital Stati�
(s gnature)
ipi District Number lit(0( Place p.{_y_x ,`nk
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
i .
ill Date of Disposition • la )1 ii3 Place of Disposition -en/Ott,../ ta rate',LA^
(address)
lit
IA
CC (section) ��lot number) (� (grave number)
e ` J
O Name of Sexton or Perso in Charge f Premises a,�'( 4" t'
it
2 (pleas print)
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Signature 7L,._ 5' Title aEINTICIa
(over)
DOH-1555 (02/2004)