Mayehoff, Elizabeth NEW YORK STATE DEPARTMENT OF HEALTH • �1 `�
Vital Records Section Burial - Transit Permit
Name FitstI Z� � J U (G►-,l l " �Q,. s • $e
>'�! DateCa48 th If Veteran of U.S. Armed Forces,
c � War or Dates
=' Plac ath Hospital, Institutio o ,,�, 1
r
Ci. ,Town Viliag l,t Q Q�S _ Street Address �1 �-r�'l' ` /C_rS.l n p,�
Manner o Death Natural Cause Acc' ent Homicide [�Suicide Undetermined Peng
Circumstances Investigation
Medical rti tier N me n ( .\ I Tie `
i Address �� (?�-t...)--e.),--- )-3./d 1 r t--C + 6
11",",, Dea ' ate FileCy) Dis ' t Number RueterNumber. C ,Town or illage -l`2�1�4'j i �9 _ 1 �p
�
Date � Cemetery or Crematory
=>: 0 Burial •
Address -
:` 0 Cremation
. Date Place Removed
Z❑Removal • and/or Held
and/or Address
Ei Hold .
6 Date Point of
t1 0 Transportation Shipment
Ll by Common Destination
Carrier
1:1 Disinterment Date Cemetery Address
:_ Q Reinterment Date Cemetery Address
Permit Issued to ,�+ 1 � Registration Number
': Name of Funeral Home T CL SOtJ {Title 4 0- il2h L 5'6'r
in Address b ' W IL<<.I- HIA. N . ta�S--i
ti; Name of Funeral Firm Making Disposition' � Wiat
or to.Whom
Remains are Shipped, If Other than Above
Address '
K Permission is hereby granted to dispose of the human:Tr ains described a ve as indicated.
• Date Issued 1 S 10 .3 Registrar of Vital Statistics G- Q.
: (sign re)
l d -� i,,s-e .$)
-�`"� District Numbe���� Place b ls--r� .. . : . •
f" I certify that the remains of the decedent identified above were disposed of in accord ce wi this permit on:
-vi• Date of Disposition 1{1111.5 Place of Disposition ;.roaw.+ CronA f Orko-,
(address)
•
i •
(n
c (section) t number) ( (grave number)
0 Name of Sexton or Person in Charge of P mises r,3 2r s N+.ri+
/� (please print)
41 Signatu?e �'`r Q __ -.�.. Title - C cji ft Q?
t�°� (over)
DOH-1555 (9/98) •