Bisbee, Inez NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name JF�irst � Middle La Se
/ (
Date of gab . Agef3 If Veteran o . Armed Forces,
,-.,e, / lam
/2/)—' War or Dates
14 P ce of Death Hospital, Institution or
ZCr Town or Village Street Address �//s Ili
/ `tti• anner of Death atural Cause Accident Homicide Suicide ndeted PendingUj ❑ ❑ 0 6 ❑
Circumstances Investigation
W Medical Certifier N me Title
O �G -a/ Q R11kaVSeG1kGG' � „
//‘C/ ‘Zi/a774-,5-7: cr-cii-eji€e.j4.e4 - (I-y /„..7(.3.c ,?
. :i::. Death Certificate Filed District Number Register Number
City, Town or Village
ii 0 Burial Date Ce tery or Crematory �/,
❑Entombment / 3h. ' ; /2Z, l/ 1 a)(f2�I 6f/d'./ d/r1i1 -
Add ss l� L p
Cremation C( t � ,�� 6PtJ- -etif � -�f �O-U e V
Date Place Removed /
43, ❑Removal and/or Held
and/or
Hold Address
O Date Point of
M` Transportation Shipment
O by Common Destination
li Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to ��-�-- Registration Number
Name of Funeral Home ca � 2_1- 7 �j i?r-- ham/'Y/
Address `�
kE Name of Fu eral Firm Praking Disposition or to Whom
I . Remains are Shipped, If Other than Above
', Address
tr
to
:1` Permission is hereb granted to dispose of the human ins desc e ab e indicated
iRi Date Issued %)Registrar of Vital Statistic ..e/e/xt
(signature)
District Number Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
LEI Date of Disposition fcl,hl Z (L- Place of Disposition i,_,LUt ,, iottw—._
a t (address)
ILI
to
cc (section) ` , (lot number (grave number)
O Name of Sexton or Per on in Charge o Premises 7L1 r Jt``-lj{-
6 (please print)
9
Si nature �\ Title Ceti inkli!i_
(over)
DOH-1555 (02/2004)