Abrams, Fetar , ill
NEW YORK STATE DEPARTMENT.C,F4iEALTH
Vital Records Section Burial - Transit Permit
Name Firs � Middle iLast Se�1-��
Date of Deat A e If Veteran of U.S. Armed Forces,
War or Dates
#- Place of Death Hospital, Institution or ))
City, Town or Village IW-�/?�l,03? � Street Address
Manner of Death atural Cause [—]Accident ❑Homicide ❑Suicide Undetermined ❑Pending
ILU Circumstances Investigation
0.
tU Medical Certifier Name Title
Address 3ar
U icJi
Death Certificate Filed District Num r .g Register Number
City, Town or VillageQ• /'/�'L�' � _�'`/ ��
❑Burial Date Cemetery o CrematoIr`y
❑Entombment
Address D
remation (f er�� 1� /v
Date Place Removed
Removal and/or Held
- and/or Address
Hold
O Date Point of
❑Transportation Shipment
by Common Destination
Carrier
❑Disinterment Date Cemetery Address
Reinter Cem etery Address
ment Date
Permit Issued to _ Registration Number
Name of Funeral Home
Address
yj
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
tt
Permission is her by ranted to dispose of the human r ai described ve as indicated.
� .
Date Issued Registrar of Vital Statistics
(signature)
District Number c7 Place`_s�'!�i`�� r
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition S�-jp-ZOZOPlace of Disposition �21 0-y
r (address)
(section) (lot number) (grave number)
Name of Sexton or P o rge of Premises �� `^
(please print)
Signature Title'
(over)
DOH-1555 (02/2004)
Public Health Law Sec. 4145(2b) 01.3703
Receipt
i
Human remains of r° delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#