Hayward, Helen M NEWYORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Biostatistics -Vital Records Section
Name First Middle Last Se
:......:::: ...................................... g--- ....
Date of Death Age If Veteran of U. .Armed Forces,
War or Dates
.......... ... ...........................................................................
:..::::::::.:::::::::::::
Place of Death Hospital, Institution or
City,Town or Village ; Street Address
Cause of Death #j
Medical Certifier Name n Title
::::.....................................................................................................
l� l
_............................. N ............_................... �
Address
h1.
Death Certificate Filed :: Distnct Number Register Numbes
City,Town or Village
'. Date Cemete rr Crematory
❑Burial
3v
!Cremation `. Address
Z; Date Place Removed J
0 El Removal and/or Held
and/or Hold :::::::::::::::::::::::::::::::::::::::::::.:::::::::::::::::::::::::::::::::::::::::;>::::::::::::::::::::::::::::::::::::::::.....:::::::::::::::::::::::::::::::::::::::::::::......:::::::::::::::::::::::::::............... ::::
Address
Q>:::::::::: ......::.::::::::>::.:::::::::::::::::::::::::::::::,:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::.:::,:::::::::............::..:.....................................................................................................
t5 Date Point of
i.V i ❑Transportation by:. Shipment
CommonCarrier ...............................................................................................................................
Destination
.......... .... ....................................:::::Date::::::.................... ............................. ::. .:::::. .......................................................................................
❑ Disinterment Cemetery Address
.............. ...........................::...:::Date::,::......................................... ....::>:::Cemete .::.::.::::::.r::::::. ......................................................................................................
❑ Reinterment Cemetery Address
Permit Issued to Registration Number
Name of Funeral Firm
_:::: : _ ....... _. . _ _........ G -
Address
....... .......... .. .. ...... .... ...................... ............. .... .. .......... ......... ................. ..........
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
a
Permission Is ereby granted to dispose of the human remains
- described above as Indicated.
Date Issued J 3 Registrar of Vital Statistics /J
, a
(signature)
District Number J� Place /
1 certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
u Date of Disposition Place of Disposition T 6L!�_�
{address}
w.
(section) (lot number) (grave number)
p Name of Sexton or Person in Charge of Premises ` Gyl �� L ���i°z�
Z (please print)
Signature Title- &,0 76
DOH- 1555(9/86)p 1 of 2(formerly VS-61)