Potter, Madalene NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Biostatistics-Vital Records Section
Name Middle Sew
Date of ahy
Agee If Veteran o . . r es, � ,
r
War or Date
Place of Deat Hospital, Instil do 0
,AuCity,To r Village � � Street Address
Cau of Death
a
et i Na The
id
D to File "'yam istri Nu I.(!... ................................................................................................
i Register Number
City,Town or Village — /� L/��
D e C etry o rsmatory
Vn ❑Burial x/
remation
. ate Removed
0 ❑ Removal i nd/or Held
and/or Hold
t�` > Address
14.
0>:::............................:
:IL: Date Point of
N' ❑Transportation by Shipment
Common >:::::::::::::::..:::::::::::::::::::::::::.:,::::::::::::::::::::::::::;>:.:::::::::::::::::::::::::::::.:.::::::,.:::::::::::::::::::::::::::::::::::.................................................................
Destination
Date .................................................... ............................................................................ ...........................
mi, ❑ Disinterment Cemetery Address
❑ Reinterment
Date Cemetery Address
iNi Permit Issued to Registration Number
Name of Funer
al raIitFm
Address
/
': . . . . , -/
Name of Fe
irm Making Dis it n o o hom
im Remains are Shipped, If Other than Above
:tfl:
Address
Permission is hereby granted to dispose of the hu re ns c abed , 'bove as Indicated.
iiiiiiiiiiiii Date Issued ��� �i Registrar of Vital Statisti
signature)
I District Number , / Pla ._., -5 — /���/
I certify that the remains of the decedent identified above were disposed of in rdance with this permit on:
Date of Disposition 6-8- S, Place of Disposition // /V4 V/�4) C 7,5 1? M/9 P,/JAi
;E:, (address)
'Ai
jp, (section) (lot number) (grave number)
o: g 4I?4J/9/QD 47 972iWitJ
p;• Name of Sexton or Person i Charge of Premises
z (please print) p
u.l Signature Title 17,4720/9 /D,y /iss� / ,
DOH-1555(9/86)p 1 of 2(formerly VS-61)