Hayes, Elizabeth NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Biostatistics -Vital Records Section
Name First d Middle Se
Date of Death Age If Veteran of U.S.6ped Forces,
War or Dates
Z Place of Death Hospital, Institution or
City,Town or Village Street Address -
Cause of Death r
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Medical Certifier m� Title
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Death Certificate Filed „...;:...District Nu „................ Regste Number
City,Town or Village 'S � C 3
Date Ce ery or Cremato M1---s�
❑Burial '
tyCremation Address
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Z Date ace moved
O; ❑ Removal and/or eki
and/or Hold :......::::::::::::::::::::::..:::::::,::::::: :::.. ....:::::::.::::......::::::::::..::::::::::::::;::: ::: .::: ::::::::.::::::::::::::::
Address
p Date Point of
.th: Transportation by Shipment
p Common Carrier
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Destination
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Disinterment Date ; Cemetery Address
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Reinterment Date Cemetery Address
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Permit Issued to C Registration Number
:.:. Name of Funeral Firm . `�
israi m e
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Address
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Name�of Funeral Firm Makin Disposition or to hom �
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Remains are Shipped, ff Other than Above
Address
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Permission is ereby gra ed to dispose of the hums emainsdescri!b�ed above as indicated.
Date Issued, Registrar of Vital Statistics
ignature)
District Number Place
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
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<W
Date of Disposition _ Place of Disposition
g address)
GC'
(sectio (lot number) (grave number)
p4 Name of Se n or erson in Charge of Premises
Z (please print cc
w Signature le �LSl —
DOH- 1555(9/86)p 1 of 2(formerly VS-61)