Tassell, Dale NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name�� Midsjle Last Se
/37
Mi Date of Death Age...... If Veteran of U.S.Armed Forces,
A Sr a-0/5 o War or Dates /00)
Z Place of D ath Hospital, Institution or A,/635
W City own +r Village /fch( �vcSG� Street Address p �' &y . 'qs, 1_ovvd Ny
Manner of Death Natural Cause Accident Homicide Suicide � Undetermined � Pending
Circumstances Investigation
?w Medical Certfier Name Title
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ddress
Ililililli PP. 111---i 'ia 1-`4 4— D4c..; k N,)-7-. I.79-q(-76
Death Certificate Filed � + District Number Register Number
Ci own Village / Uhl h V t� ll�S ____ /
Date / Ceme r Crematory
❑Burial PI a y .:.:.a 7 ..:...... /s /V12a0/P44I ehd ,o T v'-
Cremation
Address
u. ems 6 r r)7Y.:..
Z Date Place Removed
O ❑ Removal and/or Held
i— and/or Hold ... .::.::..: ...
Address
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0
a. Date Point of ..
N' 0 Transportation by Shipment
p1 Common Carrier
Destination
Disinterment Date Cemetery Address
Reinterment Date CemeteryAddress
Permit Issued to Registration Number
Name of Funeral Fir GCJA,,-d h gv,ki,`71 / cl�e r. �el ..: Q'B 5 t y: .
Address
I i\i /as-'--2�
: Name of Funeral Firm Making Dispositionor to Whom
$> Remains are Shipped, If Other than Above
Ir Address
>tu>
Permission is hereby granted to dispose of the human remains described above as indicated.
i �-�- n ; .
Date Issued A a � l�o Registrar of Vital Statistics
iiiim
(signature)
District Number /�� Place f -3-'' /j /d$0z.. •
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition 6)mil S Place of Disposition
e, -
(address)
W
N (section) (lot number) (grave number)
p' Name of Sexton or Person in Charge Premises !/Sri c..�tr+1
ZAt (please print)
W Signature Title 04001W
DOH-1555 (10/89) p. 1 of 2 VS-61