Johnson, Martha NEW YORK STATE DEPARTMENT OF HEALTH 5 1 N
Vital Records Section Burial - Transit Permit
Name First Fityltzeidd 't: Last Se
Date of Death Age If Veteran of U.S. Armed Forces,
/A/a 7`U 62 7 / War or Dates
}- Place of Death Hospital, Institution or
W City, Town or Village 31,641.4 caLf2a2- Street Address
ci Manner of DeathIT]Natural Cause ❑Accident ❑Homicide ❑SIliuicide E Undetermined ❑Pending
U. Circumstances Investigation
W Medical Certifier Nam Title
Ad r ss a y>
Death Certificate Filed District Natliber Register Number
City, Town or Village Ji �.� kli;--- .J t e
❑Burial Date Ce tery or Crematory
['Entombment102 iol 0% 4, �-„- 1/"� -''
i
Address
WCremation �tG n ( �c.v��l,aQ `'�/� 71 y
Date Place RerrYoved
X❑Removal and/or Held
and/or Address
F Hold
0 Date Point of
!l ❑Transportation Shipment
0 by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home 24.�, 0 ii y
Address
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
I
lI
a` Permission is hereby/ granted to dispose of the human remains desc"bead above a indi d.
Date Issued /c2I /bk Registrar of Vital Statistics ,t=ter%: :'
/
(signature)
District Number 5 / Place ���
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k
W Date of Disposition 12/;t 7/G.L Place of Disposition f,,,iri r�, Cr ,,)4 I,,,�,
111
(address)
CC (section) i/ J (lot number)
ber) (grave number)
i' Name of Sexton or Person in C arge of Premises t h t S pn�z tf
�l�/� (please print)
Ili
Signature L. Title C ,t 'cr
(over)
DOH-1555 (02/2004)