Wright, Iwing NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First • Midi Z/dast
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Date of De't ' Age If Veteran of U.S. ed Forces
/�. .. .. g/ War or Dates
PI a of D ath Hospital Institution��or// f
z Cit own or Village .. -(.J Str eet Address �`G .......... ......_ .
Manner of Death 1---. .......::: ndetermine............ d Pending
Ne atural Cause Accident ❑Homicide ❑ Suicide Ei
Circumstances Investigation
-yam
Medical Certifier me • .) Title 4
•
ddress
De h Certificat Filed District Number Register Numbe
it Town or Village •YL? —V— ( 6 7
Date e t or Cre�matory
gBurial iG ///�9/ ..../,.'.. ..t.� .......... ......... ........
0 Cremation Ad+r —y�
z Date Plac emoved 7'
A ❑ Removal and/or Held
i—'' and/or Hold
Address
N'
a Date Point of
N Ei Transportation by Shipment
pCommon Carrier ...:.. _...:..........:......... ........... ,,:,,:. :....... ..: :::::.:. ......,: _. ... .....::..
Destination
Disinterment Date Cemetery Address
1:1Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Fun irm - / 't �fo0
Mi Address
CX::G::..:. .. ..:.::....:.....:......:. ...:.:...:........ .:.... ..:. ::.. ,: : /1-gip./..... ..... ...
Name of neral Firm Ma ing Dis1posi' n or to Whom
2'. Remains are Shipped If Other than,Above �
: Address
Permission is hereby granted to dispose of the hu i remains described a ove dicated.
iiiiiil, Date Issued /0%/9/ Registrar of Vital Statistics
n. (signature)
>i District Number .�/4i / Place ./ Xells, /z
aconce with this permit on:
I certify that the remains of the decedent identified above were disposed of in
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WDate of Disposition / -//- / Place of Disposition �?✓--=-J jc-i1./ (,•=:yc f /. (72Ut?�<.'.;`4, 4 1 i07
(address) / F
vi al., c /. /
cc (section) (lot number) (grave number)
O
p Name of Sext or rson in Char a of Premises ,o v &'/ / �4 / i_c -- a
Z (please print)"
ul Signature c` Title S5! 7`.
DOH-1555 (10/89) p. 1 of 2 VS-61