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Malloy, Marie NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle La Date of Death Age If Veteran of U.S. Armed Forces, War or Dates Place of Death Hospital, onpf City, Town or Village Street Address Manner of Death© aiural Cause A ident Homicide Suicide Undeter med Pending Circumstances Investigation Medical Certifier Name Title �} Address Death Certificate Filed Di ric mb Register Number City, Town or Village SQ Date Cemeter r Crega#�iry >. El Burial Address [3Cremation Date Pla emo 0❑Removal and/or Held �•• and/or Address E� Hold V Date Point of Q Transportation Shipment G by Common Destination Carrier Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Address Name of Funeral FirMaking Dis ition or&Z Whom Remains are Shipped, If Other than Above Address Pav-niissicsn iS he"eb-- grantGu to dispose oil-tie iiLi�an, rai-aai tt c ed akc,ve f icated. Date Issued Z Registrar of Vital Statistics !� (signature) District Number / Place IT I certify that the remains of the decedent identified above were disposed of in accordance wit his permit on: Date of Disposition� Place of Disposition P/ (address) UJI t/J L>E: (section) (lot n wn ber /grave number) QName of Sexton Person in Charge of Pre esDd� � 1,9 74J z (please print) Signature Title d DOH-1555 (10/89) p. 1 of 2 VS-61