Burritt, Hugh NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First / /� enzotp. ,� �M'ddle ithigig s Sex
Date of Dea Age If Veteran of U.S.Armed Forces,
/c2a1y 6 7 War or Dates
i Place of Death / / Hospital, Institution r ..�
W City,Town or Village t/ , S ' 4 S Street Address G rS Si-t-S/ �` .
p Manner of Death ruNatural Cause Accident Homicide El Suicide Undetermined ri"—I Pending
W CircumstancesInvestigation
W Medical Certifier Name A Title
Address ,/
Death Certificate Filed District District Number Register u b r
City,Town or Village t it1s a cS ��
• ❑Burial Date Ceme ry or Crematory �,
El Entombment C� -/®.,6/�� /it) ifI L c�,9 c Cil.�6 tt-y
= Address/ &t ^ e_ R ,r y
Cremation C�.�Jv �£�JS�4c..�+2y /v�/ ,�[! �
Date Place Removed / /
Z Removal and/or Held
O and/or Address
h Hold
0 Date Point of
ej Q Transportation Shipment
0 by Common Destination
Carrier
0 Disinterment Date Cemetery Address
0 Reinterment Date Cemetery Address
:4 Permit Issued to Registration Number
I Name of Funeral Home 0/09�.t t! f �/t!'�. ile cs
Address
,. /56 id/9-,e.,egki 6wa,43 2‹,tC--S 'A)/ 6a-3/
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped, If Other than Above
2 Address
CC
W
aja,` Permission is hereby/ granted to dispose of the human remains described as i d.
Date Issued 0,PS/9OI y Registrar of Vital Statistics /Oki
signature)
District Number(5-6(fJ Place &/ens r9//4. ,/y Jr? /
HI certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
z ,.. (�..,
W Date of Disposition 'II 1,5I►� Place of Disposition ,a"9'��
2 (address)
W
Cl) (section) jot number) ,_ (grave number)
pName of Sexton or Person in Charge of Premises `�r�"��o��`^ `""''i
Z (please print)
W Signature Title CN ie FflOvt.
(over)
DOH-1555 (02/2004)