Wood, Frank A NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name EjFst Middle st
tt�t f.
Date of ath Age If Veteran of U. rmed orces,
< r--�-71 L — War or Dates _
' Place ath / --rr�am Hospital, Institution or
C , Town r Village C�9 r: Street Address
eath 1 Natural Cause Accident ❑Homicide ❑Suicide ❑Undetermined Pending
��--PP�� Circumstances Investigation
Medical Certifier Name Title
}" Address
Death C icate Filed District Number _ Register Number
CiV-owq 0 Village r - Lf
Date Cemetery or Crematory
❑Burial s / ,a.� �vtp V��� (fjL c �
Address
[ Cremation «„� N
Date Placb Removed
Removal and/or Held
-•• and/or Address
Hold
Date Point of
VJ Q Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
-T Reinterment Date Cemetery Address
Permit Issued to ]� Registration Num er
Name of Funeral Home �r rR—_ G It`t
�v
Address
j Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hpre y granted to dispose of the hu n remai descr� a indicated.
` Date Issued Registrar of Vital Statisti
(sig ature)
Place
District Number
I certify that the remains of the decedent identified above were dis o ed of in accordance with this permit on:
Date of Disposition Place of Disposition jpJ7a-
(address)
(section) (lot number) (grave number)
Name of Sexton or rs in Charge of Premises
g (please print) /
Signature Title �ieOr
(over)
DOH-1555 (9/98)
Public Health Law Sec. 4145(2b) 4_
Receipt
I
f
Human remains of delivered on , 20
Pine View Cemetery Reptsentint[he funeral home named on burial permit
Official Funeral Directors Reg.or License#