Towers, Lois NEW YORK STATE DEPARTMENT OF HEALTH'
Vital Records Section .Burial - Transit Permit
•
•i Name First Middle . ...�-� w Last Se
s •
'' Date of Death Age If Veteran of U.S. Armed Forces,
A 1 r / a orb- 1S`f War or Dates •
'L P . - of Death ! Hospital, Institution or
-. .wn or Village 6L- Street Address , t, -1-C e /4
>�;►"'per of Death — Undetermined Pending
� Natural Cause �Accident �Homicide �Suicide � �
Circumstances Investigation
Medical Certifier Name Title
s ,�} H Ott..D
Address �
iiiiii i a a . Pettit Sit
i J 6 L?l., 4. 1i7 0 , i. 1 �%O
>` e-. h Certificate Filed / District Numb. , / Register Number
ity, •wn or Village C9.Z 'Tait,- 5 & D_1- Ss
Date Cemete r Crematory ' i
❑ Burial '2/ 3 /av /1- i'/ ve� Cr -�-1-,,r
Address
7 Cremation C & s.. ''f n , %/ L
Date Place Removed
ZO E Removal �" and/or Held
and/or Address
• Hold
.0 Date Point of
NTransportation Shipment
E by Common Destination
Carrier
Disinterment Date Cemetery Address
— Reinterment Date Cemetery Address
Permit Issued to ` Registration N ber
Name of Funeral Home ' •• S '�> K "i,.t 4/ ( 14 - O6`r'tr 1
IIAddress
r
.
W r..40\6--s- 4v e
lea r.
Name of Funeral Firm Makin Dispo nor to Whom
= Remains are Shipped, if Other than Above •
Address
Permission Is hereby granted to dispose of the human remains described above s In at d.
'�> Date Issued � /S /1 Registrar of Vital Statistics
A.#‘-f7I
i . i
(signuc3-�
iiiPi
•
0 District Number 3 C 0/ Place ( / �c� %D(�1
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: 1
'i
E Date of Disposition aPi 1w Place of Disposition 's ` 1 J ( td(NA-
(address)
li.I
CC (section) (number) (grave number)
Name of Sexton or Person in Charge of Premises ,,i :r. 3t -
2 / (please print) r�
4.! Signature ` Title aconffq
• (over)
DOH-1555 (9/98)