Darrad, Edward P. NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First M' dle Last Sex
h All,
Date of Death Age If Veteran of U.S. Armed Forces,
War or Dates
Death Hospital, Institution or/
City, ToWn or Village Street Address
1-fd6nner of Death Natural Cause 0 Accident Homicide Suicide Q Undetermined Eltending
Circumstances Investigation
Medical Certifier Name 11 Title
Address _
h•1
Death Certificate Filed / District lomb Register Number
n or Village
Burial Date Cemetery or Crematory
❑Entombment
Address
[Cremation r
Date Place Removed
❑Removal and/or Held
and/or Address
Hold
Date Point of
Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Regia�ti Number
Name of Funeral Home G ^SM 2.r C- r
Y'
Address
rr�. �e G � rlL—
Name of Funeral Firm Making Dispositi n or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains descri e ov as i ated.
Date Issued �t �� Registrar of Vital Statistics �!<<
(signature)
District Number Slued Place ��,�— j �G w
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition -3*41--2o1 o Place of Disposition kz; e,j c!-r-
(address)
(section) (1f t number I (grave number)
Name of Sexton or Person in Char of Premises �iA� rJN (�c�G�
(please print)
141
Signature S Title k�c
(over)
DOH-1555 (02/2004)
Public Health Law Sec. 4145(2b)
-,5446
Receipt
Human remains of . .. 4
� , a� . ; f,...._. delivered on ,� � 20_
�� .
Pine View Cemetery Rtpr enting the funeral home named on burial permit
Official Funeral Directors Reg.or License#