Campbell, Mary iz
NEW YORK STATE DEPARTMENT OF HEALTH - /VC)
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
�� ri r E . C U ,,�� c) ) ,S"'
Date of Death Age If Veteran of U.S. Armed Fortes,
3) )5 ) , War or Dates
}- Place bf Death Hospital, Institution or
III City, Town or Village -',rG)..o Street Address r4.�oe �4;,p
W Manner of Deatir Natural Cause Accident El Homicide El Suicide ElUnde r.Wined �-Pending
�� Circumstances Investigation
tu Medical Certifier Name Title
C
Address
Death Certificate Filed District Number Register Number
cCif Town or Village SA2A i'OGA SPRINGS g50/
❑Burial Date 2 Cemetery or Crematory
['Entombment3) ) `N>) 13 tom'0'c 2/'c ".> Cr c`r°'m'4- a +�
Address /j
Cremation Qi_s� cr q.v.) «ti\sz,-.)7 ,I .siy _
Date Place Removed
Removal and/or Held
and/or
Address
IZ. Hold
tin
O Date Point of
ft❑Transportation Shipment
G3 by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home t �e r, �,�,, 5-4-4-,{-C�J) Q) 9 9 z/
Address
Name of Funeral Firm MakingQ position or to Whom
}► Remains are Shipped, If Other than Above
• Address
IX
III
Permission is hereby granted to dispose of the human remains ribed above as indicated.
Date Issued Registrar of Vital Statistics 0-QM -P- -41,.„1),
(signature)
District Number 4tSd/ Place a!'; ",TOGA SPRINGS
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI• Date of Disposition 3-(8-i 3 Place of Disposition ) 10 trc_ \i, `z ) (j(F,,,,A P)-d R--y
2 (address)
ILI
CC (section) .i,' (lot number) (grave number)
o Name of Sext. 'or Pero in Charge of Premises S�C "TT /J�O W 1 �C�
2 / (please print)
W.
Signature 11Y/; Title . "`19-6Z �S-) -
(over)
DOH-1555 (02/2004)