Banning, WilburNEW YORK STATE DEPARTMENT OF HEALTH _ a
Vital Records Section Burial - Transit Permit
Name First Middle t
Sex
Date of Death
Age
If Veteran of U.S. Armed Forces,
`l a 7
War or Dates
P of Death
%Ci own or Village_�; -�
Hospital, Institution or Itt
Street Address 3 S St
anner of Death [fl Natural us A cident Homicide Suicide El Undetermined Pending
LW
Circumstances Investigation
U1
Medical Certifier Name- Title
Address
e Certificate Filed
Town or Village �r,4, `�
Dis rict Numbe Y_
Register Number
El Burial
Date Cemetery or Cremator r
�)�V
❑Entombment
30 �
Address
Cremation
Date
Place Removed
Removal
and/or Held
and/or
Address
Hold
Q
Date
Point of
Q Transportation
Shipment
0
by Common
Destination
Carrier
Q Disinterment
Date
Cemetery Address
Reinterment
FEJ
Date
Cemetery Address
Permit Issued to �—
Registvatiop umber
Name of Funeral Hom C„SM� "< " ,�c ^ -J-�-
l� 77
Address
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
5
Address
Ili
Permission is hereby granted to dispose of the human remai escribed above as indicated.
Date Issued L Registrar of Vital StatisticstL qVU/r'4-k
(signature)
District Number L Place zcfnaa
I certify that the remains of the decedent identified above were disposed of in a ordance with thi ermit on:
ttE
Date of Disposition 1(3ulll Place of Disposition 4;yt+r�
(address)
(section) /lot number) (grave number)
171
Name of Sexton or Person in Charge of Premises �'r���--
I (ple se print)
Signature !�- Title w IDS -
(over)
DOH-1555 (02/2004)
PUB6C 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 (02/2004)
Public Health Law Sec. 4145(2b)
012563
Receipt
Human remains of �% �� ".,^ delivered one' , 20jj
r
Pine View Cemetery ✓ Representing the funeral home named on burial permit
Official Funeral Directors Reg. or License # 1 '