Imrie, Maurice NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Date of Deajh Age If Veteran of U.S. Armed Forces,
14/'9 r/S 7 War or Dates
,:k. Place of Death Hospital, Institution r
City, Town or Village ff� Street Address �'1� �
Manner of Deaths Natural Cause Accident 0 Homicide Suicide Undetermin Pending
iij Circumstances Investigation
Medical Certifier N e Title
se.
_ti
Address
-- _ _
Death Certificate Filed District Number Register Number
City, Town or Village -slid I / 7 4
�-�/ Date Ceme Cr
ematory.
or Creatory
E Burial fit l if 7 ,,�.,,4 44_601/
Address
❑Cremation g_p-e- ,27
Date Place Rem ed 7',
d ri Removal and/or Held
and/or Address
H Hold
O Date Point of
5 0 Transportation Shipment
b by Common Destination
Carrier
0 Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home4,,,,,,;4,.._ -,/, Q/g 7 -7
<> Address
7 i h f . /2- I-, V
Name of Funeral Firm Making Disposition or to Whom
:1i Remains are Shipped, If Other than Above
it Address
14
L -
Permission is hereby granted to dispose of the human remains described above as indicated.
<>; Date Issued f seo /ot 7 Registrar of Vital Statistics .*A (,t,�„",.y-J „_
(signature)
'` District Number .63(a/ Place 4,,ge- ,-, Tie - ,J T,
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
f--
WDate of Disposition 4/li/97Place of Disposition p; ne View r' m t ry .QneP.,shnry ,�Y
W (address)
N Mohawk 27&28 3
CC (section) (lot number) (grave number)
gName of Sexton or Person in Charge of Premises Michael Lopez
z (please print)
W Signature Title Working Foreman
DOH-1555 (10/89) p. 1 of 2 VS-61