Loading...
Lamphear, Helen NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Vital Records Section Name First /� fiddle L Se�� - / ..._ .. Age Date of Death If Veteran of U. Ar ed Forces, War or Dates ZPlace of Death �� Hospital, Institution or ui City Town or Village Street Address / W Manner of Death Et Natural Cause Accident Homicide ❑ Suicide . Ondetermin d Pending Circumstances Investigation W Medical Certifier Name itle . D Address Death Certificate Filed j /� /District N mber Register Number City,Town or Village �• . ,ten '"`4" 7 v , /5 Date Cemetery or matory , ln Burial �(1/ re2.,...,-,4,----7 .- Cremation Address Z Date Place Remov 0 0 Removal and/or Held i- and/or Hold Address u, O [t. Date Point of ['Transportation by Shipment In Common Carrier • Destination • Disinterment Date Cemetery Address ▪ Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Firm '� i >� G u 0 Address /^ �� ( 1- Name of Funeral Firm Making Disposition or to Whom 2 Remains are Shipped, If Other than Above CC Address ui .a . .... Permission is hereby granted to dispose of the human remains cribed above as /indicated. Date Issued �/� /�,3 Registrar of Vital Statistics ��tiC.,,-fic J (signature) District Number ,_S-ZD / Place i� /-2- v/ 3' z I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z Date of Disposition 3^a C^73 Place of Disposition p j N U/e,G,U C.2,I Q T{,("y 2 address) W Th z iC,g4ti ls' N" / NCC (section) (lot number) (grave number) O p Name of Sexton or,.- 'Peersonn in Charge of Premises Alf!'.h 45L hB PGZ— W Signature (Please print) Title GU © i rk r fit/,Gf / r e- `) DOH-1555 (10/89) p. 1 of 2 VS-61