Pitkin, DAvid NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First, ` Middle Last p. �, Sex
Date of Dgath Age If Veteran of U.S.Armed,Forces,
_ 0. /r3 / 13 �� War or Dates 4gLO ' 0 Scj
,.,.., Place of Death Hospital, Institution or �.� ck
City, Town or Village Street Address ��1 �}"
Manner of Death g Natural Cause 0 Accident 0 Homicide 0 Suicide 0 Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
LW A �` A• G►\tQc\► n V
Address
S0-a ea,Lsi CAL.v s F4tls) WLt lab i
Death Certificate Filed District Number Register Number
`' City, Town or Village Oc\e \-e--r 5(cS Z.
Date Cemetery or Crematory
❑Burial a /i4 1%l 3 Q-t nt \)1►_� C_r•C- c-.
ff��II Address /�., `` `
IG-Cremation l.y.vG f ��^ e_2�S�vY-� / {v� V - Q 1
Date Place Removed
Z❑Removal and/or Held
... and/or Address
.. Hold
V)
Date Point of
wQ Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
>: Permit Issued to Registration Number
>s Name of Funeral Home i)�s\g \O.r C cV c\tc-LA k':" ®m t CO 1-N4 V
pi Address
3.-
iii; Name of Funeral Firm Making Disposition or to Whom
rr Remains are Shipped, If Other than Above
Address
W I_
Permission is hereby granted to dispose of the human r=mai,s,d=s ib ove a indicated.
gi dj Date Issued 1 /f Registrar of Vital Statistics i ' r�
(signature)
NiiN:: District Number Place , 2j,& ILlc ii die„,:t...r,e}c_,)
I certify that the remains of the decedent identified a cove were disposed of in accordance with this permit on:
F /�
taz Date of Disposition j-►q-►, Place of Disposition R +tv [,ndr.tigr,‘►•-\
2 (address)
Ui
('3
(section) (lot number (grave number)
0 Name of Sexton or Person in Charge of Premises hr, 2,,,, -
Z (please print)
W Signature________4_t______j Title Ceeimio a4�
(over)
DOH-1555 (9/98)