Huntington, Iola F NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Biostatistics Vital Records Section
Name First Middle Last sex
....... .....
...................)t.'.............. ......
Age If Veteran of U.S.Arm Forces
Date o eath
War or Dates
. ....... ...Place b
A(
eath.. Hospital, Institution or
"
City,Town or Village Street Address
............
Cause`o**'*f*'Death
.................
U, Medical Ce ier Name Title
Ad Ir
Death Register Number
Filed mbar
City,Town or Village
7
Date U Cemetery or Crematory
❑Burial
'J-9- jF
Cremat
ion .2L
..........
Date
z Place Removed
Removal and/or Held
and/or Hold..
Address
Date Point of
0 Transportation by
Shipment
p. Common Carrier ......
Destination
❑ Disinterment Date Cernwery Address
..........
❑
Cemetery Address
C
Reinterment Date
Permit Issued to i.igistration Number
Name of Funeral Firm
'4 - ...............
Address
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 dqAd4uman remains described above as Indicated.-
Date lssued/'2e, 1,/j j qe Registrar of Vital Statistic Lee
(signature)
7,�� Place (2
District Number
V
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
. ' Date of Disposition Place of Disposition e, u i e.(t/ C 9 c m cA.To-A i L) M
UJI
24 (address)
oC
(section) (lot number) (grave number)
0
0:. Name of Secton or Person in Charge of P:c rnises 4 15 1, U C)P e-Z_
(please print)
L.0
:71 Signature.44az Title
DOH-1555(9/86)p 1 of 2(formerly VS-61)