Chattin, Howard NEW YORK STATE DEPARTMENT OF HEALTH t C) U l
Vital Records Section .� Burial - Transit Permit
Name i First Middle Last Sex
Ir
Dat f De th Age j If Veteran of U.S. Armed Forces,
C/- 6 �� War or Dates
Place of Death Hospital,Address 9 / U e ,VyS G 1'
ei City, Town or Village gy1-e, Street Address LL T * N Jty T
pLLI Manner of Deathatural ause Accident Homicide n Suicide Undetermined 0 Pendir�(g
f Circumstances Investigation
Fu Medical Certifier Name ,. Title
Address Pair),
'` Death Certificate Filed '�_! District Number- Register n{ber
gi City, Town or Village jf r 9 (d ( 0 :� 7 E L lj
Dat .yy �J C etery or Crematory )
['Burial (l'/ �' C rnd_ tr;eliv (_/n
Address �� (J
kCremation 1'00
Date Place Removed
0 ❑Removal and/or Held •
and/or Address
M- Hold
Q Date Point of
0 Transportation Shipment
G by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
EH 0i PermitIssued to Registration
tio�n Number
Mi Nameamed of Funeral Home ¢ 7, rlvz_ (�� /`/
Address
iiiiiiiii 5 3 > - ,_. nf1 off, i 2 Sr6 y
...>,.: Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
aAddress
Iiiil
• Permission i hireb granted to dispose of the human re 1.1 s described ab 'Is indicated.
Date Issued 77 /7O(.0 Registrar of Vital Statistics ilrze � ( )--r��-)
/� signature)iiik
1^
iik District Number �� Place /j}t.c-� _ ZY y tc .
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
f-
WDate of Disposition 1/0/oi� Place of Disposition ',etc vvP:,•) C re 5tt>r)o-vn
2 (address)
iu
(/)
CC (section) /'(r (lot number) (grave number)
GName of Sexton or Person in Charge of Premises ( h'�s S�n,�,r (,�
g C 4t ,)y � (please print)
• Signature Title C r-crrc; to t'
DOH-1555 (10/89) p. 1 of 2 VS-61