Smith, Daisy NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
;:. Name First Middle Last Sex
iin
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Date of Death Age if Veteran of U.S.Armed Forces,
D/a&'19 t War or Dates ...............
Z Place of Death Hospital Institution or
W City Town or Village �t.�-�® Street Address
G-.Manner of Death: :::. ..:-.....: :: .: � � .
W Natural Cause ❑ Accident ❑Homicide ❑ Suicide U e�fined Pending
14 Circumstances 1.11 Investigation
ill rt Medical Certifiers. Name Title
c... . 7 ... Tl -::........: r
Address
,7tf
..............
Death Certificate Filed Dis ict Number Register Number
City,Town or Village oZtei 1. cezig, S7,0 1 57(.0
Date Cemete or CrematoryIg( �v
Burial /:�9i.: .. .. ..:..:. ...:..... ...... ...... ,.c
❑Cremation Address
Z Date Place R r
oved
0 0 Removal and/or Held
H and/or Hold .::.
Address
0....... _ .................................. ................................. ........ ..
o_ Date Point of
N 0 Transportation by Shipment
p' Common Carrier
Destination
❑ Disinterment
Date CemeteryAddress
Reinterment Date Cemetery A
Permit Issued to Registration Number
Name of Funeral Firm / r O/9D
Address
;- : Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
....Address .:...
ittr
a
Permission is hereby granted to dispose of the hu an remains described above as indicated.
Date Issued 70/4 d /4/ Registrar of Vital Statistics C. &441,0
��//�� (signature)
District Number 5 Z'O/ Place s--, �,4.I 0 7 _
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
F-.
W Date of Disposition // 51 y/ Place of Disposition /9ti - 17/r=44i /t- wY/ t L/ -L-''f_:Cel/f y) rJ
(address) L
W f ?11�Sc).4. , /y-/
CC (§ection) (lot number) (grave number)
p` Name of Sext Person in Charge of Premises /7 o[> �'r.- /7/oSM<=
W I�1 (please print)
Signature '. _ .��G/.1 ,0. Title -'L-e !T r
DOH-1555 (10/89) p. 1 of 2 VS-61