Perkins, Bruce A. NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
rK vt i
Date of Death Age / If Veteran of U.S. Armed Forces,
20
O War or Dates
Place of Death Hospital, Institution or r� ,! ' "
Z City, Town or Village lj Street Address 5 / gG� C� Hv� 7 S
W Manner of Death Natural Cause Accident ❑Homicide ❑Suicide ❑ Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name Title
Address
� #01-m l'/ ,-9� , Saie��v /tJ /z MCP
Death Certificate Filed District Number egis er Number
City, Town or Village 5 G
❑Burial Date CtC ery or /remato
K),e V 1 -e- [_ z e `lce
[]Entombment Address
Cremation QeefV S i(.e// IZ
Date Place Removed
❑Removal and/or Held
and/or
Address
Hold
O Date Point of
❑Transportation Shipment
by Common Destination
Carrier
Date Cemetery Address
❑Disinterment
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home
Address
/ ve S fo S P
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 human remains described above as indicated.
Date Issued -Z, -2-0ZURegistrar of Vital Statistics , __--
u (signature
District Number Place !2 (�
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
1LU Date of Disposition `IIZ!IZp Place of Disposition F.L �f�
(address)
(section) lot number) (grave number)
Name of Sexton or Person in Charge of Premises (1jr„ 11�
Z. (pleak pant)
Signature �- Title �IZfi-04�t/l
(over)
DOH-1555 (02/2004)
Public Health Law Sec. 4145(2b) 013,584
Receipt
Human remains of delivered on 120
Fu
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#