McGarr, Marilyn NEW YORK STATE DEPARTMENT OF HEALTH ! / 3
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Date of Death Age If Veteran of U.S. Armed Forces,
War or Dates
Place of Death Hospital, Institution or
City, Town or illage Street AddressJfidion &ee ,VwS„
Manner of Death Natural Cause ❑Accident Homicide ❑Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier _ Name Title
/�. Ze
Address
12,
Death Certificate ed District Number Register Number
City, Town o ffllage
ate A/;/7
metery or Crematory
El Burial G % eUreca Cretn,.�-1,il-iU M
Address
®Cremation
D to Place Removed
0 ❑Removal and/or Held
�- and/or Address
Hold
Q Date Point of
❑Transportation Shipment
by Common Destination
Carrier
❑Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home p f
Address
. e,
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 rem s described ove s indicated.
Date Issued Registrar of Vital Statistic '
(signature)
District Number Place lor" /
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
f- i� (rJ
w Date of Disposition Place of Disposition A H l E�) Vnn �F-! �/�� q-r0 P T
2 (address)
LU
N
t>: (sec on) �u beer)+ (grave number)
0 Name of Sexton or Person in Charge of Premises R--
g (please print)
y Signature t Title E l''(/��� /9
+OR % Sr fi
DOH-1555 (10/89) p. 1 of 2 VS-61