Hutchins, Peter NEW YORK STATE DEPARTMENT OF HEALTH "r SZ
Vital Records Section 4. N Burial - Transit Permit
Narrten First Middle Last + Sex
`tom-/-C.-bt +ilk*hi r s 1 M -.
Date of De th Age _ ! If Veteran of U.S. Ar ed Forces,
i &3 I10 J War or Dates
} Pla a of Death I Hospital, Institution or
4 City.�fow Dr Village )v d(.ay} ( k Street Address a70 6lq t3rvp
Manner of Deathmilvi Natural Cause El Accident El Homicide Suicide Untermined �Pending
� de
Circumstances Investigation
Medical Certifier n Name
Title
okuU / 0LQ .
Add ess
Death Certificate File ^ � I District Number Register Number
City. ow or Village j(ct-yl ' o ' 70 1
Date C etery or rematory
❑Burial i I -2S -Z O 1 ('A Q:m_a
Addres J
®Cremation
Date Pla emoved
O❑Removal and/or Held
and/or Address
Hold
CO
Q • Date Point of
Q Transportation Shipment
ES by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment 1 Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home(, _ 0 I I Cr!
Address
Name of Funeral Firm Making Disposition or to Whom j
Remains are Shipped. If Other than Above
Address
Permission is hereby granted to dispose of the hums em "ns describe a ve as indicated.
Date Issued 1 la51 13 Registrar of Vital Statistics\--. i '[ j_ (-O('j f .)on
a f_____, (��rgnature)
District Number Place I
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
M
Date of Disposition 1-1g-t3 Place of Disposition '1r uJ rwr.,
Ili
2 (address)
I;LI
CC (section) Ai(11Frr,rib (grave number)
GName of Sexton or Person in Charge f Premises g w
Zr (please print)
LU Signature41*-- Title C ieit.
DOH-1555 (10/89) p. 1 of 2 VS-61