Greene, Silas NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sexx-
J1\ctS y. re e. C`l c,n
Date of Death Age If Veteran of U.S. Armed Forces,
i( 7 t‘ 2)r-) War or Dates I,J
f4 Place of Death Hospital, Institution or y�
City, �bv or Village q l\tR ,Y\\ Street Address �'C'C t rt S trA + 'K2h4
Manner of Death a Natural Cause El Accident 0 Homicide 0 Suicide rl Undetermined 0 Pending
Circumstances Investigation
La Medical Certifier Nam Title
fir- ,e \f\6e.\l t NkTh
Cp( Address
C (j,mot 1.�� l
Death Certificate Filed District Number 'iegister Number
City, oW or Village c.r,v Z,&. '‘A _ 5' ') S (0 a
«'❑Burial Date C etery o1r Crema�t ry^
❑Entombment I `i t rl to- )t) �
L.�(tY`t" - LP4'v
Addres
remation (_,.u..c ,-- ( ) -r o. livi
Date Place Removed
9 D Removal and/or Held
and/or
r;; Address
+
Hold
0 Date Point of
12 Transportation Shipment
by Common Destination
Carrier
Mi
Q Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to Re istration Number
>! Name of Funeral HomeQc '� ° i� el'C s-_ bL \OL
Address!iii!! - .. ),t,1s,f- a 1,) 2S1)-1-
1
Name of Funeral Firm Making Disposition or to hi
14 Remains are Shipped, If Other than Above
Address
ce
ui
P" Permission is hereby granted to dispose of the human remains describ d abo e as indicated.
Date Issued i t Registrar of Vital Statistics uxtt Gtig
(signature)
District Number L7 56 Place '0 ,�� c-rvt'1 l
certifythat the remains of the decedent identified
above were disposed of in accordance with this permit on:
k /'�
I Date of Disposition rig I 70it Place of Disposition ,+,s 0,2,v C ivh-4to(It
(address)
lAi
CC (section) (lot numb (grave number)
Name of Sexton or Pers n in Charge of remises a r:s1-vfly r imeli-
2 /� (please print)
Signature l ' � Title (e k hrt i 0 ,,.
(over)
DOH-1555 (02/2004)