Reed, Florence NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First,„/ Middle A aast Sex
illiig fr/Oef e•VCC. /4".
...
beie.642f:iee.it,, ie • : Age ''''''' '' ' If Veteran of (.1.S. ArmedForces
7 7 r 7, War or Dates
Place of Death Hospital, Institution or
i.:!4 City,In or Village ,4h, Street Address
P..Manner of Death LE Natural Cause 0 Accident El Homicide 0 Suicide 0 Undetermined n Pending
:1.11 Circumstances" Investigation
iipu....Medical
Certifier
..........i\iai.n..''........................ 1........ ..... . . . .......... ....... ............................... ......... ......... ..... .. .
Title
Meg IC /710 iC- 3 t 14) 41 Li . .
Address
...... 6 4 , -(4. A).Y
Death Certificate Filed is • ' District Number Register Number
City,In or Village if%*/14 57eli <9...
Date Ceuetery or Crematory
12 Burial 9/4/7/9., 0.c.lpe gew GoeivmAgia/v
Cremation
Address
•,... W
aeeor do/er/ irli •
.... . ..
z. Date Place Removed
0 0 Removal and/or Held
. and/or Hold ...Addie..s...s............................... ..... ... ...... .. ................. .. ... . .... . .. .. . •
:•(r).
0................................ ......... .. ... .... ........ ........ . ..... . . .., ... .. .... .. •
Date Point of
Transportation by
Shipment
Common Carrier -• ....... •:•.. ........ ........ ........ ...... ......... .... ... . . . '
Destination
.. . .. .. . .. ....... .. . . . .. .. • •
Date Cemetery Address
Disinterment
. .................. ............. ........... ...... .......... ............................... ..... ......... . ...... ...... ... .............. ........................ .......... ........ ...... ...... ...
Date Cemetery Address
Reinterment
Permit Issued to i 1 Registration Number
Name of Funeral Firm 41Ve ,,,(1 Aie.e.407...... ..407// ce 0 4,Zi 9
... •
Address
%Veell /V1/
1.4 Name of Funeral Firm Making Disposition or to Whom
i, ,
mii Remains are Shipped, If Other than Above
Xae-i Address
illk
4)Z
Permission Is hereby granted to dispose of the human remains described above as indicated.
Date Issued 05P/r/F, Registrar of Vital Statistics "iittZke Kt.-(1ktA OC .
(signature
District Number c7er V Place c..X (fite /1/Z
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition ?-5-e?i" Place of Disposition e.--7-7 /1/2/9 Zr574/
cu
(address)
cu
cn
cr, (section) (lot number) (grave number)
0 7-159d
c3 Name of Sexton or Person' Charge of Premi es k----Pt 4)/9/e D
/9
please La
Signature print) Title e-- fi,e—/1//97C)/e)/ hi-5-5f(7---(
DOH-1555 (10/89) p. 1 of 2 VS-61