Tosse, Florence NEW YORK STATE DEPARTMENT OF HEALTHS ' ti J s3
Vital Records Section Burial - Transit Permit
Nam first Middle Last Sex
VI Drry e 1__-___ 7isse_ RMi Lr
Date of Death Age 1 If Veteran of U.S. Armed Forces,
I U— )(o—0-0 I a ' WO I War or Dates 1•Jo
Place e_o Death ; Hospital, Institution r /� ) ,t
Ci . Tow or Village 0 u.ez , ,bjU Street Address ���� %� 1- 1�`1 �!�r It/
Manner of Death I'll Natural Cause 0 dent Homicide Suicide Undetermined Pending /
,¢� g _
Circumstances 'Investigation
Medical Certifi Name U Title
L1 �1�iJ
Address �,
I Death ificate Filed \ District Number Register Number
..3 Ci ow or Village Qv -n5 btiY� E h510 C"7 { .
Date / C etery''o//r Cremat ry L,,
❑Burial JD / 7_ )0., Hh-E View k7l 7ZT /
Addr
Cremation+;
. ve0-15bury Ny
ZDate / Place Removed
0 Removal _ ! and/or Held
r- and/or Address
to Hold
Q Date Point of
gS Q Transportation ; Shipment
aby Common Destination
Carrier
Disinterment
Date Cemetery Address
Reinterment Date i Cemetery Address
a Permit Issued to �-- Registration Number
Name of Funeral Home r-eL -f t,�y % 1 40 yylky / 60,9(/
Address
c Ciurn (St Lh L,(z , Ail /ag 6/6 _
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped. If Other than Above
Address
Permission is hereby granted to dispose of the human re sins described//abov as indicated.
Date Issued /J-/ -)-I, Registrar of Vital Statistics ...i .— -Y —' -
(signature)
District Number SZngm Place l --1,4i,t. LA",._--
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
t-
WDate of Disposition tc-^tSr-,‘2olL Place of Disposition r-tec,h"eui C1`.evna' Lvan
(address)
W
U)
se n)� (�t.
t number) (grave number)
Name of Sexton or Person in Charge of Premises 4.410 L j e vt
�� (please print) r
44 Signature41 Title C!`ern4, 55?
DOH-1555 (10/89) p. 1 of 2 VS-61