Mason, Orion� M
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
ame Fir t Last
r n
Date of beath
'---20
Age
If Veteran of U.S. Armed Forces
9f
War or Dates
es
Place c�ath
C�r'LAfll
1
Hospital, Instituti
017� k�— q /0
City, �T�Jbr Village
Street Address -
Manner of Death Natural Cause [:]Accident ❑ Homicide Suicide Undetermined Ej Pending
Circumstances Investigation
Medical Certifier Name Title
Addres,
V1
Death Certificate Filed
District r
Register Number
City, Town or Village
I
Date
CeLnetery or Cremat ry
El Burial
V I
®,Cremation
Acld�e,��
t LA
Date
Place Removed
0 Z
❑ Removal
and/or Held
and/or
Address
Hold
0
Date
Point of
Transportation
Shipment
by Common
Destination
Carrier
Disinterment
Date
Cemetery Address
Reinterment
Date
Cemetery Address
Permit Issued to
—F:4,e
Registrationmber
)0
Name of Funeral Ho
Address
se ve
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
y gran ms describ?edpbovyas indicated.
Permission is h reb granted to dispose of the hurnalernay
Date Issued' q Registrar of Vital Statistics�-A�Ez��
V(si nature)
Place�
District Number42-
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
z
W
Date of Disposition tOLY4 — Place of Disposition pj'-C� 14-c,- cr-&8Q.1ary
2
.
(dddress-)
Uj
(section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises Tcf LIX q-L 9 11 J, I-c-
(please print)
Signature Xz�� Title c,rfe4. &f
FAK
DOH-1555 (10/89) p. 1 of 2 VS-61
Public Health Law Sec. 4145(2b)
Receipt
Human remains of
Pine Vie<Cemetery
Official
r
delivered on
012592
20 r
Representing the funeral home named on burial permit
Funeral Directors Reg. or License # I ;� 4 ` �j