Mooney, Mary NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First �� Middle Last Sex
IAAOD _
✓ Date of Death Age If Veteran of U.S. Armed Forces,
0'7- f, -7-0IZ Ill War or Dates
e of Death Hospital, Institution or POrvilf-
,,,;` own or Village �PcjZi-ra(91% Street Address � .Alt-S
.nner of Death Natural Cause DAccident Homicide El Suicide Undetermined Pending
f Circumstances Investigation
III Medical Certifier Name Ji I '' Title
V i i�tN W tenet J\Ji&.M PM ell fT 1c5
Address
i 3-2-- L- R.I.. Nis-I-ATM,A_ XIy 1Zi
h Certificate Filed District Number Register Number
✓ ''"<; City, own or Village 5� $ 3(:):2
,:all-Burial Date CerOtery or r c� �matory/J
[]Entombment d�' !! 0- V i Co N,� 7-17W
Address /2 remation CIA/FP/AID t4 / /Q V 121
Date Place Removed
gIn Removal and/or Held
and/Holdor Address
it
0 Date Point of p
cliN El Transportation Shipment
G by Common Destination
Carrier
Q Disinterment Date Cemetery Address
iiiiigQ Reinterment Date Cemetery Address
<> Permit Issued to h � � J� Registration Number
Name of Funeral Home hiou .pU _ I4Dv4- 001:2L.
Address
Z9 P>Natvi) q-1. I* 2144Prrat4164 to 117Mc )
Name of Funeral Firm Making Disposition or to Whom t
Remains are Shipped, If Other than Above
Address
It
LEI
Permission is hereby granted to dispose of the human re ' s s 'bed s Indic d.
iii:$ii Date Issued 9112_120I 2 Registrar of Vital Statistics
(signature)
District Number 1_460 I Place r��-�0, -x cp Y l� !2 % Up
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ill Date of Disposition 1-13-1 L Place of Disposition 'P..t uu (,►.44,iu-..-
(address)
JAI44
CC (section) f (lot number) / (grave number)
Ck 5tt Name of Sexton or Per on in Char of Premises sriT r tw/�'�-
(please print)
Signature Title Ca'C0144011
(over)
DOH-1555 (02/2004)