Kingsley,Willis VS 61 (Rev. 7/79) New York State Department of Health
BURIAL — TRANSIT PERMIT
Name: First Middle Last Sex
w- 1<' ri 1�
Date of Death Age If Veteran of U.S. Arm Forces,War or Dates
F., 0 u
W Place of Death: City,Town or Vill '' 99
HoEnstitution or Street dress
4-!/ vy a[•k C� (0 6)
C auses of Death:
U A
W Medical Certifier: Nam Title Address
A c c,, rn F ram. r�t r
Death Certificate ile ) City,Town or Village District No. Register Nod
❑ Burial: D Cemetery or Crematory Address
Cremation:
z Removal Date Place Rem ved and or Held Address �—
O ❑ and/or Hold:
F�
rn Date Point of Shipment Destination
Q Transportation by
A, ❑ Common Carrier:
QDate Cemetery Address
Disinterment:
Reinterment:
Permit Issued To:Name of Funeral�FF n Address l/ --// Registration No.
94
Name of Funeral Firm Making Disposition or to Whom Remains are Shipped. If Other Than Above:
H Address:
Permission is hereby granted to dispose of the dead human remains described above as indicated
W Date Issued —3
p Registrar of V4t�'l Statistics (Sigrwture)
District No.0 6- f:2
Place
his permit must be completed on back by the person in charge at the place of disposition and filed with the registrar of vital statistics of the city,town or village
where disposition took place.