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BURIAL — TRANSIT PERMIT
/Name: First( / '- }ildle /'7��1C_' ��/ Last Sex
Date of Death 7 / Age If Veteran of U.S.Armed Forces, ar or Dates
H • //,i Town 7 I g/L(/-77
Z Place of Death:City, own or Villa , L Hospital. Insti u ion or Street dres
w Causes of Death: _ J ' ✓
O (4a� Le
W Medical Certifier: Name qe a Address
Death Certificate Filed:City Town or Villa a i District No. Register No.
,..,% Date O/
P Burial: // Cemetery or Crematory�1 Address
❑ Cremation: >/A-2 /g'j� i?...e.--j---t , /�,c-er/ (...,l-�-�.. CGt- �r ,.�j
Z Removal Date r Place Removed and/or Held Address
0 ❑ and/or Hold:
Fi
rn Date Point of Shipment Destination
p Transportation by
a. 0 Common Carrier:
cn
ADate Cemetery Address
Disinterment:
0
Reinterment:
Permit Issued Nam f Funeral Fir Ad ess Registration lo.
26
Name Name of`Funeral Firm Making Disposition or to Whom Remains are hipped, If Other Than ve:
F- Address:
c4Permission is hereby ranteq,to dispose of the dead human remains described abov- : drated
W /� ZL �� _
Q" Date Issued ty _Ai.2004;1 ,
�6OI Regime. f ital S _aturr]�j
District No. ' j
ace
his permit must be completed on back by the person in charge at the place of disposition and filed with the registrar of vital statistics of the city,town or village
where disposition took place.
PUBLIC HEALTH LAW
§4145. Deaths; burial and removal permits; disposition of remains.
1.No person in charge of any premises on which interments,cremations or other disposition of the body of a deceased person are made
shall inter or permit the interment or other disposition of any body unless it is accompaniedpy a burial,cremation or transit permit,as provided
in this article.
2.The funeral director or undertaker shall deliver the burial permit to the person in charge of the place of burial or other disposition,before
interring or otherwise disposing of the body;or shall attach the removal or transit permit to the box containing the body,when shipped by any
transportation company,which permit shall accompany the remains to its destination,where if within this state,it shall be delivered to the
person in charge of the place of burial or other disposition.
3.The person in charge of the place of burial or other disposition shall endorse upon the permit,the date of interment,or cremation or other
disposition over his signature, and shall return all permits so endorsed to the registrar of his district within seven days after the date of
interment, cremation or other disposition.
4.When burying or otherwise disposing of the body of a deceased person in a cemetery or burial place having no person in charge,the
funeral director or undertaker shall(a)sign the burial or removal permit,giving the date of burial;(b)write across the face of the permit the
words"No person in charge;"and(c)file the burial or removal permit within three days with the registrar of the district in which the cemetery is
located.
5.The person in charge of the place of burial,cremation,or other disposition shall keep a record of all bodies interred or otherwise disposed
of on the premises under his charge,in each case stating the name of each deceased person,place of death,date of burial or disposal,and
name and address of the funeral director or undertaker, which record shall at all times be open to official inspection.
ENDORSEMENT OF SECTON OR PERSON IN CHARGE OF PREMISES.
I certify that the remains were disposed of in accordance with the permit on the reverse side on 11— Z Z-8 Z--.
(Date)
(Place of disposal and ad ress)
Section AIM i et,IV f‘0 PAY Lot No.L 7, Grave No. /6
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Signature \ 0-5rX Title