Maida, Marie 4t .504
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
iddle
Name First
M M , , Last Sex
ax( ..e. A - /VI a (d
Date of Death Age , If Veteran of U.S. Armed Forces<
9 -do--d 0/,9.. 9 7 ' War or Dates A i r)
:I.:, Place of Death Hospital, Institution or i
69trl Village G 1.4 CU)5 6 th-L. ' Street Add -/-C1/11-0 n i\ht,rS///q I At''WI
Manner of Death .t.:1 Natural Cause' D A ident 0 Homicide El Suicide 0 Undetermined :rending
Circumstances Investigation
-.f1a3 Medical Certifier
N Tr
..6, ,
12
Ao:-.-- -ess
11: ,,_)\.1.,ry P. gO II
... ,
,,.. Deattl,Ceqificate Fili:6 I *ct Nu ber Register Number
--':- Citor Villag u e e nsioun I/ Co n 1 fac-\
Date 1 2_ 2 _J/ CrZy or Crematory
0 Burial 0 10 ,0 a e v I es-a)
Address p---N
'Ng Cremation l ( 11): Li u$,J... J_Vi___ R191
_• Date Place Removed
-ic r—IRemoval and/or Held
01 1 —
r4... and/or Address
a Hold
0 ' Date Point of
OS 0 Transportation Shipment
0 by Common Destination
Carrier ,
Disinterment Date Cemetery Address
Reinterment
Cemetery Address
El ;r Date
- '.- Permit Issued to Registration Number
Name of Funeral Home .Go-c,rnexe2d32reteinc__ 6oa / I
Address .
ht.t.rr
,H. 'i-Name of Funeral Firm Making Disposition or to Whom
.t... Remains are Shipped. If Other than Above
Address
ilk_
Pe.
Permission is hereby granted to dispose of the human remains described above as indicated.
Date IssueR I 2-CQ bOk; Registrar of Vital Statistics 4"-Y,.....,._ Q. !Ls_
„... •
(signature)
District Numbecr-9c-1 Place
I certify that the remains of the decedent identified above were disposed of in acc rdanc with this permit on:
Po Date of Disposition ti I:41 IL _ Place of Disposition
111 t att.) Cre440 el v 4.-
2 (address)
ILI
th
CC (section) (lot number) C (grave number)
° Name of Sexton or erson in Ch ge of Premises /14.5keiirr- --)tiwit
z (please print)
W Signature Z. Q Title fivIIKTO It
DOH-1555 (10/89) p. 1 of 2 VS-61