Teachout, Orville NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Nam First Middle Last Sex
',Jr V I I it_ 15. i tack ou+- gait,
Datel of eath Age ! If Veteran of U.S. Armed Forces,
Li PI 40 l ' War or Dates no
8 Place of eath I Hospital, Institution or _i
City. T m- r Village SI orgy G-.cK ; Street Address J 3 1 Kipp I nq 6--anch U .
Manner of Death Natural Cause El Accident Ej Homicide El Suicide ❑Undeterfnined Pending
Circumstances Investigation
�. Medical Certifier Name Title
Address
Wa_AXQ At /1-bw
Death Certificate Filed I strict Number . Register Number
City,�ownwor Village S--rjr�J C i ,� ` 36Y5J
Date eteryor/Cremato
❑Burial 041,93 aDl a ,Y1L_ V i_2-
siAddress
I1vCremation! q
Date PI Removed
Z
O ❑Removal and/or Held
k and/or Address
to Hold
0 Date ' Point of
rt.
Q Transportation Shipment
5 by Common Destination
Carrier
El
Disinterment ; Date Cemetery Address
Reinterment Date = Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home -B ,(i.)-e.A)R-L,LA_ Ali I, q--10.y4( p / .)(_,G, ' DC� i
Address
� ef, ,1 cr, _4t . , /d 81-CC __
Name of Funeral Firm MakingDisposition or to Whom ��<
Remains are Shipped. If Other than Above
Address
Permission is hereb granted to dispose of the hu a re sins described b 'cated.
Date Issued 41 I), Registrar of Vital Statists gam. ,..,9. _ A.
(signature)
�y�District Numbe3 �Y
Place 1 Ot, 1 4 \31-01 ��.I � A...40_e_aC
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
1-, �W Date of Disposition ,I111,/rt iuU Place of Disposition ,w 60-eforr,..-
2 (address)
ill
VI
Cam? (section) //� number)C (grave number)
0 Name of Sexton or Person in Char of Premises `' r, r —*lilt
g (please print)
Ui Signature /8.— Title atIh14-T6yC
DOH-1555 (10/89) p. 1 of 2 VS-61