Petrie, Arthur NEW YORK STATE DEPARTMENT OF HEALTH )` , +► 77 J
Vital Records Section Burial - Transit Permit
Name First �� Middle J Last��� r Sex
W in . _
Date of Death �/ Age If Veteran of U.S. Armed Forces,
d" 'ZS -Z�/�� it War or Dates f q67 — /4S-9
Place of Death Hospital, Institution or
illG, Town or Vittage idl in- Street Address �� J(d�� /1
Manner of Death Natural Cause Accident - Homicide Suicide Uridetefmined Pending
US O Circumstances O Investigation
ttj Medical Certifier Name Title
74nn 4'/InN16`2r. ilia -
Address
.2 /frir( /gel *JO �� i� LI47' &eii6Death Certificate Filed ) ct Nu ber / Register Nufnber
City, Town or Viltage .�/ //n S
Id/
::' 'OBurial Date Cemet ry o�mato
; ['EntombmentAddress d �� �j� r ��� � %
[,Cremation aUan ob , //
Date
Place Removed
Removal
and/or Held
and/or Address
t. Hold
Date Point of
Q Transportation Shipment
by Common Destination
Carrier
0 Disinterment Date Cemetery Address
O Reinterment Date Cemetery Address
:s Permit Issued to Registration umber
Name of Funeral Home 'irt/L5 f i( l ovv/ /// ( 99y
:: Address
7 c3/2(11$/7 /V /n/?71 AY/2 PZ-
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
<> Date Issued cS -/5- Registrar of Vital Statistics 4 /1/ l` ///,
r.
signature)
` : District Number Place 11v�J 4/3/ / // i
;< I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
214
to Date of Disposition _ gin/in- Place of Disposition feu+..) r.,v._
(address)
Ili
= (section) 4 (lot number) (grave number)
et Name of Sexton or Person in Charge of Premises t At, &ii*
2 it please print)
Signature Title 4/1006At
(over)
DOH-1555 (02/2004)