Hall, Baby NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First o Middle L /� Sex%
iRiii BR b /3 y ,
Date of Death Age If Veteran of U.S. Armed Forces, 0
-- / — re? /1I S � M o ;a War or Dates
JO Place
e of Death g �� 4A----r'
Soital, Institution orCit , T a Street Address
N Manner of Death latural Cause 0 Accident 0 Homicide 0 Suicide riUndetermined El Pending
Circumstances Investigation
PA Medical Certifier Name A i, Title /AA
Address -
S' 9 /1-1, el 1' (� s % .�.�310T �s"e``, s ,"_
iNi Death Certificate Filed j , District Number / Registe�Nmber
City, T /�� �/ sC ,
Date / Cp,;(../ e_
tery or Crematory
❑Burial — 2_ Z. --1 P' U/e--c c-' �U ,4-�.."
Address
®Cremation (e Lk,e </5 6 w - 41 /
Date Place Removed
0❑Removal and/or Held
-. and/or Address
Hold
E
0 Date Point of
NQ Transportation Shipment
Gi by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
iiiiiii Permit Issued to r- ,/ Registration Number
i i 3 Name of Funeral Home ,/dam o dJ L ,, I"
iiiiiiii;i Addres/d `v,- LA-ec2 /T U e_ d',./--"4,-7:-:A. --/-7*
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
`''i< Permission is hereby ranted to dispose of the human rem - s d c ed above s in 'cated.
11111 Date Issued '7/'"1 '_3"Registrar of Vital Statistics e
(sign re)
I /
District Number 'i/ `�'Ste/ Place 7- -
I certify that the remains of the decedent identified above were disposed of in accordance with this permiton:
r ,Q /d i!1
ill Date of Disposition 'o `rPlace of Disposition!!! ,(E //� &HEM//
M (address)
LIJ
(I)
CC g (, ,0 i91717 � (lot /n Xe�'k.1 (grave number)
Name of Sexto or Person in Charge of Premises // �
(please print) �-- ,Q
Signature + Title G/?K,/�7_ y /7�s1- r
DOH-1555 (10/89) p. 1 of 2 VS-61