Maida, Stephen VS 61 (Rev. 7/79) New York State Department of Health
BURIAL — TRANSIT PERMIT
Name: First Middle Last Sex
Date of Death G�� Age, If Veteran of U.S. Armed Forces,War or Dates
WPlace of Death: A o illag ospital, Inst tion or Street Address
AD
Im
UW Causes of Death: j
Cf��/ C�✓'1�+ c�
AMedical Certifier: Name dTitle, A dress
Death Certificate Filed:Ci�Tgwn or Village District No. Register No.
❑ Burial: Date C metery or Crematory Address
Cremation:
Removal Date Place Removed and/or Held Address
O ❑ and/or Hold:
E�
Date Point of Shipment Destination
Q Transportation by
Q. ❑ Common Carrier:
t-4
ADate Cemetery Address
Disinterment:
Reinterm
Permit Is.4 To:Name of F ral Firm Ad R raton 1�i0.�
>
Na f Funeral Firm Ma in Disposition or to Whom Re ains are Shipped, If Other Than ve:
E� AdFress:
j�e, Permission is hereby granted to di pose of the dead human remains described abov a indicated
aDate Issued 1 `� > ' �
Re Vitals tiStics (Signature)
District No. 1
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.