Mandigo John R. NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last X-p\
Date of Death Age If Veteran of U.S. Armed Force ,
.1Nar o� Dates.
Plac ath HospitAl,institution or
-City Town r Village QQ,� Street Address
Man eatV Natural Cause [:]Accident -[]1-16micide [:]Suicide Undetermined ❑Pending
- , • Circumstances- Investigation
Medical Certifier Name Title
f
Address ..
Deat ate Filed T.Ottrict Num. Ker Register Number
City, Town o Villa erg ;
.,Date Cemetery or Kematory
❑Burial 1 w
Address
Cremation
Date Place Retnoved
0 Removal and/or Held _
and/or Address
Hold
Date Point of
N Q Transportation Shipment
by Common Destination
Carrier
0 Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home
Address
scy
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted dispose of the human described bove as indicated.
Date Issued R is rar f Vital Statistics
(signature)
��
3 District Numbetq,'� . Place •` QC—CC-)a 1\s—\
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
H ,o
Date of Disposition $I Tr 26PIace of Disposition
(address)
LLI
(section) (lot numb (grave number)
Name of Sexton or Person in Charge of Premises n�
(please print)
Signature Title
DOH-1555 (10/89) p. 1 of 2 ; '-.. i? r 1 i-}:VS-61
Public Health Law Sec. 4145(2b) 01 3 3 6 7
Receipt
Human remains of y ' delivered on , 20_
Pine View Cemetery ldpresenting the funeral home named on burial permit
Official Funeral Directors Reg.or License# ,