Morales, Eligh Miguel NEW YORK STATE DEPARTMENT OF HEALTH .. Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
! h'I
Date of Deefth A1�e J If Veteran of U.S. Armed For s,
Wee& War or Dates
Place of Death Hospital, Institution or
W City, Town or Village s� Ci A)" Street Address
aI Manner of Death Natural Cause 'Accident R Homicide 0 Suicide ❑ Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Su de e-e- In
Address
Death Certificate Filed District Number RegisterNumber
ity, Town or Village l�r
LJ Burial Date Cem ery or Cre�atory
❑Entombment �6�� i/V ' '�tU e
Address
Cremation N
Date Place Re oved
Removal and/or Held
Q and/or
Address
Hold
--
.0 Date Point of
Transportation Shipment
G by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home m /p
Address
'r-a N
Name of Funeral Firm Making Disposition or to Whom
14 Remains are Shipped, If Other than Above
S Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued Registrar of Vital Statistics
(signature
District Number Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition-/3_2020 Place of Disposition
2 (address)
(section) (lot number) (grave number)
0. Name of Sexton or r in Char of Premises
0 (please print)
L.U. Signature Title /! 619
(over)
DOH-1555 (02/2004)
Public Health Law Sec. 4145(2b) 013788
Receipt
Human remains of delivered on , 20
1
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#