Hollis, Mary d,
NEW YORK STATE DEPARTMENT OF HEALH ` 7 . if
Vital Records Section { Burial - Transit Permit
<_ Name First Middle (m Last Sex
t'-)10.r 1 ix.-\-nCA c.� 1 -ul 1 ‘mi
Date of Death Age eteran of U.S. Armed Forces,
-4\22 \ Iq 3C 1 War or Dates -"
Place eath Ho tal. _ tu tion or
City own r Village })v O..0(e.C\Sbk Street Address �qq h rot ��v�r �c�
Manner of Death Natural Cause 0 Acbint 0 Homicide 0 Suicide ri Undetermined ni Pending
Circumstances Investigation
Medical Certifier Name Title
P
Address
li Death -_ ificate Filed District Number Register Number
<.> City Town .r Village w 5(0(o0 15
Date Cemetery or�rematory)
❑Burial \ �\261g Pi i e.A. _.)
Address
i?tpreiriation akiD362.r Vii •j Qus2l1. .8-'b1-L-1-A I 12.80u - --1
Date , ; Place Removed
2 ❑Removal and/or Held
and/or Address
Hold
0 Date f Point of
NQ Transportation . Shipment
5 by Common Destination .
Carrier
Q Disinterment Date Cemetery Address
n Reinterment 1 Date Cemetery Address
e Permit issued to _ Registration Number
< Name of Funeral Home R 1_3 t`!.�2 K,,,6) -I MN C" o f/3Q
Address
J/ C, r-n,-- c' v , d 0r_.". A I f .
�` Name of Funeral F Making Disposition or to Whom , / -
0 Remains are Shipped, If Other than Above
Address -
•
Permission is hereby granted to dispose of the human r ains described above as indic ed.
``. Date Issued 1t3I J 13 Registrar of Vital Statistics 7), e 1�‘--la
II ignature)
District Number�.11DC 0 Place
.146
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition? 4 .-tot) Place of Disposition j,R.1is G ory
W (address)
IX (section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises 7c %y Sczy;t'vS
z (please print)
iJ •
Signature / Title CAelfiq,ie r
/
- (over)
DOH-1555 (9/98)