Guy, Kathleen A. NEW YORK STATE DEPARTMENT OF HEALTH :j
Vital Records Section
Burial _ Transit Permit
Name First Middle st So„
Date f De tr, Age If Veteran of U.S.Arm Forces,
War or bates',-
Hospital, Institution or
_Ci ,Town Village Street Address 17 47kq
M Death Natural Cause 0 Accident .�Homicide Suicide Undetermined Pending
Circumstances Investi ation
Medical Certifier N e TM
Address
is
Death Certificate Filed District Number
- Register Number
C' ow Villa e
Dat
Ce tery or Cremat0
❑Burial ' Z ( � U i
Addre )
remation ��,�� �u�r: _>�/c �r✓f'
Date Place Removed
Removal and/or Held
and/or Hold Address
Date Point of
Transportation Shipment
23 by Common - Destination
Carrier
Disinterment Date Cemetery Address
Ej
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home ,
f Address
: <If
�r AV,
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
} .Permission is hereby granted to dispose of the huma emai s desc ' ve as indicated.
��Date Issued 0/"���� Registrar of Vital Statistic
N (sign e)
' District Number< _
Place
I certify that the remains of the decedent identified abo a wer isposed of in accordance with this ermit on:
F
Date of Disposition Z 70 Place of Disposition
(address)
(section) (lot num (grave number)
0 Name of Sexton or Person -n Charge f Premises �. Mq
(please print)
Signature Title l�i.�r► �,
DOH-1555 (10/89) p. 1 of 2
= i .Vs-61
Public Health Law Sec. 4145 2b 272
Receipt
r
Human remains of ' j delivered on , 20�
Pine View Cemetery Repretenting the funeral home named on burial permit
Official Funeral Directors Reg.or License#