MacAlister, Louise NEW YORK STATE DEPARTMENT OF HEALTH 1+ I i d
Vital Records Section it Burial - Transit Permit
Name First Middle Last _ Sex
Date of Death Age If Veteran of U.S. Armed Forces,
/z1/, ' 87 War or Dates Ajs
Place of Death Hospital, Institution or
Z City own or Village A76-2.e, Street Address hQ"u,r,,, 7 4��:
0 Manner of Death Undetermined Pending
Natural Cause �Accident �Homicide �Suicide ttat � �
Circumstances Investigation
tit Medical Certifier Name 7�. JI� Title
fA Name '7.
1C7/7 dl0
Address
Death Certificate Fi ed District Number Register Number
City, Town or Village ifAie--z-zweix—
/
-j` ❑Burial Date Cemetery r Crerna ory
: ❑Entombment Address
{ 'CremationC2e,"--""7t-a--4- ,
Date Place/Remov
f::1 - —en-
Removal and/or Held
and/or Address
r= Hold
U)
0 Date Point of
it0 Transportation Shipment
a by Common Destination
Carrier
0 Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home A-71 , ,,6 rum 1 #-"— -- ` c9 j�'4'=
<> Address / / de
ci„,--c. ,e6, „ , /-4;‘.ey /...), .r.:M Name of Funeral Firm Making isil,„,,,- p sition or to Whom
10 Remains are Shipped, If Other than Above
Address
in
! Permission is hereby granted to dispose of the human remains described abovas indicated.
>` Date Issued ,2 a 3- 0/,2- Registrar of Vital Statistics /` .k4e.�� 9
)r___d_terte,e__ (signature)
>> District Number 464,a Place
,:;: I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ill Date of Disposition b Zq 1 /47_ Place of Disposition ES V$z,,,, CiAN'taI0":
2 (address)
tii
CC (section) (lot number) (grave number)
Name of Sexton or Per n in Charge f Premises a,,*}-1r t 1)'"
(please print)
Ili
Signature Title Me M1At b .
(over)
DOH-1555 (02/2004)