Van den Bergh, Frances NEW YORK STATE DEPARTMENT OF HEALTH i - 3
Vital Records Section Burial - Transit Permit
Name First / Middle Last S x
Date of Death Age If Vet6ean of U.S. Armed Forces,
War or Dates
Place of Death Hospital, Institution or
City ow r Village qlad Street Address S2 greJ-
Manner of Death�j Natural Caus ❑Accident ❑Homicide ❑Suicide ❑ Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name Title
David Deckile Corn k3c�c
Add ess
s S N�
Death Certificate Filed District Number Register Number
City,ro-w-'rlor Village 55
❑Burial DatePn'eteryx Cremat
❑Entombment ( - I MCA
Address
remation QQ insbu nj
rtaP Date PI ce Removed
❑Removal and/or Held
and/or Address
Hold
Date Point of
Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Re istration Number
Name of Funeral Home
Address a+ (N f_ u-rC
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is h re granted to dispose of the human rem 'ns described above as indicated.
Date Issued ( Registrar of Vital Statistics Ci
(signature)
District Number I-�'v�5'g Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition /111111 Place of Disposition U.�, ( -CAO(,,-
(address)
(section) / lot number) _ (grave number)
Name of Sexton or Person in Charge o Premises i ^r(p/ese print) I
Signature � Title
(over)
DOH-1555 (02/2004)
Public Health Law Sec. 4145(2b) 013064
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#