Howe, Lee NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Biostatistics - Vital Records Section
Name First Midd Last ,.. ..e.u.....e.... Sex
gg Datt si De th e A If Veteran of U.S.Armed Forces,
/ o /9 �y 7 le War or Dates 'Z't.d'-
• Pla.'- of P4ath . Hospital, Institution or /
:..City,Tem 1 or Villayaa Street Address._..t° )7 e a c � 1s
� Cause of�h
w Ze4dial Certif. r Name Title
.........................................................................
Address
h 1,2�
Death Certificate Filed District Num r U Reg&fer Nu er
01)
City,Tewn-er-Vill 'age ( �,.. /a / b7 6-
Date Ce ery or Crematory
❑Burial o /
Cremation
Addr
•z Date Place Removed
O ❑ Removal and/or Held
•F- and/or Hold .........:
Address
W
bate Date Point of
cn El Transportation by Shipment
CommonCarrier ....................................................................................................................................................................
• Destination
El Disinterment
Date Cemetery Address :::..: ..::.................:.................:..::.
Reinterment
Date Cemetery Address. ...........::..............:....:..............:.
•
Permit Issued to Q' Registration Number
Name of Funeral Firm 0/3
Address
iiE 0'2_2 /32,04.444,0 1 '.3 . 1.‘414,t3,1,06 _ )7 s 7, /2.e.2,
tom:: Name of Funeral Firm Making Disposi" or to m Who /
Remains are Shipped, If Other than ove
Address
:i :
Permission is hereby grantedto dispose of the dead hu an remains described above as indicated.
•
" Date Issued / /9/Wegistrar of Vital Statistics C. e
(signature) Al.S.
Districtiiiiiii ���Number Place a ,-s • �2
r
I certify that the remains of the decedent identified above were disposed of in &c'cordance with s permit on:
t—
W' Date of Disposition 7/3e`9-7 Place of Disposition P, h e C Y' `E' ih 4-tor! �)ci
gll (address)
i
o (section) (lot number) (grave number)
ca Name of Secton or Person in Charge of Premises -- J c ti ) . 12 v S 5 -1 (•
Z (please print)•Signature �-. / w Title e i 5 o oti tn C / " '
DOH -1555(9/86)p 1 of 2(formerly VS-61)