Morgan, Elizabeth NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Biostatistics-Vital Records Section
Miiii Name First - Middle Last Sex
:.....9
Date of Death Age � :: If Veteran
Veteran of U.S.U.S.Armed Farces;............................................................................
.FJ::: .:::......: .:::::::::::::::::::> 72 :< i ._Dates —
Pl • •
ace • leathHospital, stitution r.,
i4i. Cit....Tow or Villae.........0,:m'
..... ...........:........:....' •dress Zm/ ....e:....... G.rt. ........ 1.60 ...... ...... . . ._.........._......
iC] Cause of Death
it
1 '
13a
Medical Certifier Na e Title
VIP fiefde/e/ S?4/e/ A b
Address
iiiim Death 'ficate Filed � / District Number Register Number
Cit ,Towwor Village -l/44lk-e7"fg-ett.# 4/' Z—
Date etery or rematory
❑Burialri
s: Aar
gCremation �g�% -y;
Cq'
Y�
2 �� Date Place Fafo teVe'ci
O ❑ Removal and/or Held
and/or Hold ii
Address
Cl)
>o. Date Point of
V): 0 Transportation by ':' Shipment
CommonCarrier ............................................................................................................................................
Destination
;:::Date::::: Cemetery:.................................................::: Address::::::...................................................................................................
❑ Disinterment
..............................................Date.......................................................... ...... ::. ...........................................................................................................
❑ Reinterment Cemetery Address
ER •
Permit Issued to / / Registration Number
:::::::
Name of Funeral Firm . f. .._... ..... .:./'._'� h.'S._ ' ._.� .:._ e)/ ..._..................
Address
1
L/ /9 2 E. C
/4 N
Name of Funeral Firm Making Dispositioror to Whom
Remains are Shipped, If Other than Above
Address
..........................................................................................................................................................................................................................................................................
.....................................................................................................
Iiiiii Permission is hereby granted to dispose of the human remains described above as indicated.
• 7
Date Issued 7
jsf`�� Registrar of Vital Statistics Q. C
sure
District Number /J1. Z Place EVorriAk) I/. W J./v
/2/
I certify that the remains of the decedent identified above were disposed o in accordance with this permit on:
Z:: Date of Disposition 9 `l�Y Place of Disposition P ,
ij/fl, !//,c14c.✓ Z7 i�/ '//7/f 7/( '/zI
g;: (address)
'i
(section) (lot number) (grave number)
g ,�lcJ/9�D /n// 7//cW 4 a!' Name of Sexton r Person i Charge of Pr mises
z (please print) ?Fk,4/4 T� ,,Q-s rj
W Signature Title /U //
DOH-1555 (9/86)p 1 of 2(formerly VS-61)