Morse, Elsie NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Biostatistics -Vital Records Section
Name Fir
st
le
Sex
Date of D Ag If Veteran of U. .Aimed Forces,
_`"' War or Dates
..... ....................................................................................
C Place of eath Hospital, Institution or
City,Town or Village $ Street Address
/.Z2 ..... ...l..............................
€ :: Cause f Death r-
J
t
:.>. ,.:.:: <(.�. :.... . ..:. r :...................................................... .
w )'vie ical if Nam
ddre
:: Death01-0
ertificate Filed Distri Nurn Register Number
City, or Village /
... y 9 z y cv�"2,eL /�9/ w
Date CeRrerry.or Cr matory
ga urial 1 y�
Cremation
Ad ss , ��'
Z: ate ? P ce '_*oved
Q 0 Removal nd/. eld
1-: •
and/or Hold :::::::::::::::.::::::.............................................................. .....
Address
1.6
Q :::::::::::::::::::::::::::::::::::::::::::::::...:...............................................................................................
t Date < Point of
;ci ❑Transportation by Shipment
>O
• Common Carrier
:::::: :.:::::,:::::::....:................................................................................................................................................................................................
Des:: tination
El Disinterment DateCemetery Address
.................................................................................................
❑ Reinterment bate- Cemetery Address
giii Permit Issued to r� Registration Number
i; Name of Funeral Firm
,7 >
Address ::::::::::::::::::::::::::::
gipi
�O
ma..
Na uneral Firm aki g
o r to Who
ilig
3 Remains are Shipped, If Other than Above
AO
Address
it :
iSi Permission is hereby granted to dispose of the hu re ins , escribed ,above as indicated.
iliiiii Date Issued /' ,,;) --t Registrar of Vital Statistic
signature)
`:> District Number ...7 o/ Place /e,,,c..,_. a., ,7 /. �sf
I certify that the remains of the decedent identified above were disposed of accordance with this permit on:
%.14
Z' Date of Disposition/Z-Z F-561 Place of Disposition `f' ; xl c 10, e w (�'.c v .--v�) y
�j \) ,-z �v s v
<W ram)
( I
W Qir!ole a t".)CA- 1 Z-- A
rn;_ (section (lot number) (grave number)
iltr
(:1. Name of Se or P rson in Charge of Premises ti a ci n1 + Y• 1 O s s e J%-
1:211c(please print) -.
141
Signature 7 l LC q - Q Title kj pl--
DOH- 1555(9/86)p 1 of 2(formerly VS-61)