Eggleston, Cyrnal NEWYORKSTATEDEPARTMENTOFHEALTH Burial - Transit Permit
Bureau of Biostatistics -Vital Records Section
Name First Middle Spy,
S
r
:<'> Date of Dea Age ? If Veteran o .Armed Forces,
War or Dates
,•Z Place of each � Hospital, Institution o r
lij City,Town or Village , � J `" Street Address
O Cause of Death
l Medical Certifier Namee......
... .....................................................................
:4100
>I
ress
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Death Certificate Filed � 7 Distnct�u �r Register Nun�fr
City,Town or Village [� / 0Date / Cemetery o matory
trial
0 Cremation .
Address ( ...:::..::::.............. ....::.:.............:........
,....::e7,--I
Zi Date Place Remove
'10 ❑ Removal and/or Held
}• and/or Hold ...A : :: :::.::::::::::.::::::.:::::::::::::::::.:::::;>:::::::::::::::::::,:::::::::::::::::,::::::::::::::::::::::::::::::::::::::::::::.::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::
" Address
Cl)
n. Date Point
NI ❑Transportation by
C ': Shipment:
Commo< n Carrier :.:................ina....:..:... ............................
Desttion
............. ..................:..:.:..::............:.::...::..
❑ Disinterment Date Cemetery Address
❑ Reinterment
Date .:.Cemetery Address.............:.......::...:::.....................:,.:..........................:..................
gg Permit Issued to t Registration Number
€i Name of Funeral Firm � ... k- ..�. 3
Address !! /..........................L1................�f
::::>::»:
.....
'`" Name of Funeral Firm Makin Dis sition or to Whom - .` s '
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the dead huma mains /described above as indicated.
iiiiigii U b�Date Issued Registrar of Vital Statistics - ' if.t.4..,J/i-c._..1
( signature)
District Number _, -0/ Place X-e.,(..„, f J /" "
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
F
Z Date of Disposition Place of Disposition
w:
2' (address)
w
(section) (lot number) (grave number)
pName of Secton or Person in Charge of Premises
.:Z (please print)
w Signature Title
O
DOH - 1555 (9/86)p 1 of 2(formerly VS-61)