Scott, Douglas NEW YORK STATE DEPARTMENT OF HEALT'r�i /
Vital Records Section . Burial - Transit Permit
Name Firsf r
M•ddle Lift_ Sex
Date of Death �(�Lo
/���ao/� Age If Veteran o U.S. Armed Forces,
}.., Place • a-. �4 War or Dates `
HoZ Cit own o illage Cv r.u-4... Street , In tution or -
Street Address
p Ma - Death i_Natural Cause Accident �Homicide �Suicide
W �Undetermined —Pending
WMedical Certifier Name Circumstances `-•Investigation
Title
q .C9e-otd< . ex:"... K Mrs
Address (J _
p.,(,..Ad-k_ e i 61--71=314.- A),
Death ificate Filed
District Number Register Number
Cit own r Village ( � r...tSS3
— Date Ceme or Crematory�
Burial iv// /aoi ---- rg t V-ci., Lir...c j..
Address •
Cremation r`� i�
01k.ivez. / /o
Date Place Removed
!'�
Zf •1 Removal
and/or and/or Held
•- Hold Address I
0 Date Point of
Transportation Shipment •
p by Common Destination
Carrier
Date
_ Disinterment Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to -------
Name of Funeral Homec(t. Registration Number
Address
7 .5 I i er,n..-.- 4/e-
ta ,'
Name of Funeral Firm Making Disposition or to Whom I a
H Remains are Shipped, If Other than Above
4 Address
Q
Permission Is hereby granted to dispose of the human r .:
cf P scribed ov icated.
Date Issued /`3 r O� REistrar of Vital Statistics
••aare)
District Number 5S Place �/', 'f- / �,�..,. �r/�
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
H
w Date of Disposition OAiis Place of Disposition fi'l.tL C m.—
2 (address)
Er
(section)
�/�JloLmbeJtA� (grave number)
Name of Sexton or Person in Charge of Premises ( J
w
�L( (please print)
I Signature L Title 42kmet9/
OOH•1555 (10/89) P. 1 of 2 VS-61