Spring, Janette D NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Biostatistics Vital Records Section
Name First Middle Last Sex
................ ........... .......... ...........................
Date of Death Age If Veteran of U.S.Armed Forces,
................... ... .. .....
.... .......... .............................
War or Dates
.......... .........................I",
Place of"Death Hospital, Institution or
Street Address City,Town or Village
... ... .......
.b
Cause of Death
.................................
CLCfs_,A
:.i.. ........................... .........
.......................... ............. .......
Medical Certifier Name Title
lay
X........................... ..........
� d A""
.. Address A-t
Death Certificate Filed Di triolNur or Register Number
Citv.Town or Villa eZGT 2053
Date Cemetery or Crematory
❑Burial
............................... ............ ....remation ........
Address
........... .......................
�4 t
.. ........ .. ........ ......... ............ ....
Date PI.Z:
..0 El Removal and/or Hold
and/or Hold'.
Address
....................................... .. .... .. .................... ....... . ... .................................................................. . .......... ......... .......
Date Point of
vi OTransportation by:.
Shipment
Common Carrier ......... ............... .......
Destination
.......... ...... .........
............ ....... .. .. ....... ....... ...... .........
Cemetery Address Date
❑ Disinterment
............. ...... ............ ... .. ..... ......
Cemetery Address
Date
El Reinterment
Permit Issued to Registration Number
Name of Fun
eral Firm
Address
ze�
Name of Funeral Firm aking Disposition or o Who
Remains are Shipped, If Other than Above
...............
A. Address
Ok.......
........... ........ .........
Permission Is hproby gir nted to dispose of the human remains described above as Indicated.
Date Issued
Registrar of Vital Statistics
(signature)
District Number Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z� Date of Disposition c;Z-1 Place of Disposition 11f 7k/91/�l/,:5/f ,//
(address)
(section) (lot number) (grave number)
W.
0 Name of Sexton Person in Charge of Premises
z (please print) "71-
Uj Title
Signature
DOH-1555(9/86)p 1 of 2(formerly VS-61)