Moquin, Helen NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial _ Transit Permit
Name Firpt Middle Last sex
Date of Death Age If Veteran of U.S. rmed Forces,
a Z War or Dates
Place of Deat � Hospital, Institution or `
City, ow or Village / rcon ,d Street Address / JFs ZAJ„ -fe u-r1
Manner of Death�Natural Cause ccident Homicide Suicide Undetermine Pending
Circumstances Investigation
11
Medical Certifier Name Title yam,
d essC
Death Certificate Filed District Number Register Number
City, ow r Village � ,r o n c� -� / S�C
Date Cem ery or Crematory
❑Burial u 2-3 f 5`l 7 r c vi EL'j
Addre
Cremation A) Y
gDate Place Removed
8 ❑Removal and/or Held
.— and/or Address
Hold
0 Date Point of
Q Transportation Shipment
C by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to // Registration Number
Name of Funeral Home - ( C(l U
Address
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains_d scribed a e indicated.
<: Date Issued 2, Registrar of Vital Statistics
(signature)
District Number�s`y_ Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
f-
z
jjU Date of Disposition Place of Disposition /V"W"F �i
+ (address)
tl,?
>� (section) (lot number) (grave number)
GName of Sexton or Persorlin Charge of Pr mises�.cC/7lL�/��1� /1�iii 7;FP ZJ
g (please print)
Signature Title
DOH-1555 (10/89) p. 1 of 2 VS-61