Knowlton, MadoraNEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
Lei 1
Burial - Transit Permit
Name First Mid e ,� Last
Sex
Date of Death
Age
If Veteran of U.S. Armed Forces,
/D%/ o2a9Q
War or Dates
Place of Death
Hospital, Institution or
City, Town,2L Ailiae ►�(��se(��'�
Street Address
Manner of a ® Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
Medical Certifier Name �- Title
Address
Death Certificate Filed
District Number 7 G�
a
Register Number
City, Town I-i s •
O
❑
ate
Cemetery or Crematory
Burial
V
::•
Cremation
Address
Vew
Date i
Place Aemoved
Z❑
Removal
and/or Held
--
and/or
Address
0
Hold
Q
Date
Point of
-
❑ Transportation
Shipment
by Common
Destination
Carrier
❑Disinterment
Date
Cemetery Address
::
❑ Reinterment
Date
Cemetery Address
Permit Issued to
�a
Registration Nu ber
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Name of Funeral Horn�,� �„� �r,� "--e �-t.
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Address
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 rernatns, escribed above as indicated.
Date Issued Registrar of Vital Statistics (•� �c� �:r�
(signature)
> District Number Place k r
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
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LU
Date of Disposition to (z3 I Place of Disposition .��•� Lr"--i
(address)
w
(section) (lotnumber) (grave number)
0
Name of Sexton or Person in Charge of Premises
(please print)
'C*0 ATX
4U
Signature Title
(over)
DOH-1555 (9/98)
PUBLIC HEALTH LAW
§ 4145. Deaths; burial and removal permits; disposition of remains.
1. No person in charge of any premises on which interments, cremations and other disposition of the body of a deceased person are made
shall inter or permit the interment or other disposition of any body unless it is accompanied by a burial, cremation or transit permit, as provided
in this article.
2. The funeral director or undertaker shall deliver the burial permit to the person in charge of the place of burial or other disposition, before
interring or otherwise disposing of the body; or shall attach the removal or transit permit to the box containing the body, when shipped by any
transportation company, which permit shall accompany the remains to its destination, where if within this state, it shall be delivered to the
person in charge of the place of burial or other disposition.
3. The person in charge of the place of burial or other disposition shall endorse upon the permit, the date of interment, or cremation or other
disposition over his signature, and shall return all permits so endorsed to the registrar of his district within seven days after the date of
interment, cremation or other disposition.
4. When burying or otherwise disposing of the body of a deceased person in a cemetery or burial place having no person in charge, the
funeral director or undertaker shall (a) sign the burial or removal permit, giving the date of the burial; (b) write across the face of the permit the
words 'No person in charge;' and (c) file the burial or removal permit within three days with the registrar of the district in which the cemetery
is located.
5. The person in charge of the place of burial, cremation, or other disposition shall keep a record of all bodies interred or otherwise disposed
of on the premises under his charge, in each case stating the name of each deceased person, place of death, date of burial or disposal, and
name and address of the funeral director or undertaker, which record shall at all times be open to official inspection.
DOH-1555 (9/98)
Public Health Law Sec. 4145(2b) . .. J 1
Receipt
Human remains of delivered on 20
Pine View Cemetery ]Representing the funeral home named on burial permit
Official Funeral Directors Reg. or License # ;-, :4. >