Cassidy, Irene \IEWYORKSTATEDEPARTMENTOFHEALTH Burial - Transit Permit
Bureau of Biostatistics -Vital Records Section
Last
Name FiMiddlex
,„„„,
,� 5 t . /f-
iiii.......................
ate of eath I Age If Veteran of U S Arme orces
(6 War or Dates /J d
Place of Death Hospital, Institution or
j City,Town or-Village S xl !1 y- r Street Address / At rol r .. ?': :_ :.„,/ :.....
fI Cause of Death
tl] Medical Certifier) Namr Title
.
Address
Death Certificate Filed ' ' District umber , Register Number
City,Town or Village
Date 9metery or Cr matory
2 /
•
Address
Cremation , A
Z Date Place Removed
2; ❑ Removal and/or Held
F- and/or Hold .......:..:............ ... :..::.
Address
Cl)
Q
a. Date Point of
cn 0 Transportation by Shipment
p' Common Carrier
...:.:....:......:..:.....:::....:......:....
Destination
El Disinterment
:.....:,. Date ,...Cemetery Address.....................................................................................................
..: rY
❑ Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Firm -A / t ./ r
Ngii Addres
ii.;.;fi Name of Funeral Firm Making Disposition or to Whom
"" Remains are Shipped, If Other than Aboveau Address
mi Permission is hereby granted to dispose of the • :ad hu `:i remainsns,escribe. above as indicated.
Date Issued /` Registrar of Vital Statis cs !f�/��1�ii� A-'a/,.
(sib ature) -
er
District Number Place �,,,r,,-y S,Tr , Y <, f f y
miiI certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z' Date of Disposition '/L/i 47 Place of Disposition ` p . •`1 4 �ct_�- ��-� h /: 'L.)
2 (address)
ui
N':CC (section) 1 (lot number) (grave number)
pj Name of Secton or Person in Charge of Premises il h" ")
Z` ( -
please print)
w Signature i.z_,L,. . �C ; 2_ Title _/` r'-1,4 c r'
DOH-1555 (9/86)p 1 of 2(formerly VS-61)