McBride, Zoa NEW YORK STATE DEPARTMENT OF HEALTH SS
Vital Records Section Burial - Transit Permi
Name First Middle Last;:: '- _1-, c.,_ /7/.. .714-7c-gif'cle_., s,'' j
Date of Death Age If Veteran of U.S.Armed Forces,
.5--/S/ 9,c War or Dates /6
Place • _9-ath Hospital, Institution or
Ci f, Town ,r Villa e( ,,,Pe,1 s d , Street Address ,�� v y,fU yj
Mann r of Death Natural Cause U Accident [j Homicide 0 Suicide 0 Undetermined Pending
Ili Circumstances Investigation
J
Medical Certifier Name Title �/
7�s"''Gt ��e. /"/,z
3 Address
iM Death irate Filed / District Number Register Number
Ci TovSjr Villageae,, e P.in.S G7 i,✓'
['Burial Date y I Cemet ry or Creem9itory f
['Entombment Address `_ ,,..�� n/
:::CCremation �,`,,c_k,, - /l d 4' &L-t ee7.s. vi/2 , ,/ ► /i/
Date'' 1 Place Removed
❑Removal _� and/or Held
Id and/or Address
to
Hold
aDate Point of
01 Q Transportation Shipment
by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to r/� ,/� / Registration Number
. Name of Funeral Home / ca �/j.2�_(J, /S-1,1c-� 171/.?()
Address —✓ ?
e g.P. e -reoli bei e e k25 61,14:12`,4/j/ /,-;
Name of Funeral Firm-ibtking Disposition or to GVhom
Remains are Shipped, If Other than Above
Address
>I
IL
l" Permission is hereby granted to dispose of the human remains described above as indicated.
iiiiiii Date Issued i I Registrar of Vital Statistics- mow_Ct � -'L
_ (signature)
>' District Numbe c`—) Place ) c) ., � .„1)-,;
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1...„m I certify that the remains of the decedent identified above were disposed of in ac rdan e with this permit on:
Ws,
of Disposition 5-in(t2 Place of Disposition PIN
Utc.., C dr
�. (address)
it
(section) /l • (lot number) (grave number)
CtName of Sexton or Person in Charge f Premises G �I ot` �`- 3G'"i6
Z. (please print)
Signature ik_ Title Cfl3511PY
(over)
DOH-1555 (02/2004)