Cavano, Matthew(disinterment) W YO --PP'
RK STATE DEPARTMENT OF HEALTH /
Vit Records Section Burial - Transit Permit
Name First Mi le Last S
-ZL---
Date of Death Age If Veteran of U.S. Ar d Forces,
y War or Dates W
Place of Death os it Institution or
City, Town or Village ,.-a;,= t } -_ Street Address
Manner of Death❑ Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name a: w Titles
r
Address
Death Certificate Filed Dis rict Nu m r Regist r Number
City, Town or Village SpRE Z
Date % Cem or Cre t ory a
❑Burial � Q j �_�Lu �
Address
Cremation'
Date Place oved
0 ❑Removal and/or Held
•• and/or Address
k� Hold
0 Date Point of
❑Transportation Shipment
by Common Destination
Carrier
Disinterment Date ` C,meter Address, Scca fa
Reinterment Date Cemetery Address
Permit Issued to Registration Number
<> Name of Funeral Home-
Address
Name of Funeral Firm Making Disposition to Whom
Remains are Shipped, If Other than Above
Address
I.M
Permission is her by granted to dispose of the human re i s d cribed a Mve as indicated.
Date Issued 0/ Registrar of Vital Statistics
( gnature)
District Number
Place ;
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition Place of Disposition t I G(AEM P, 1 V M
(address)
Jill
(section) (lot nul (grave number)
Name of Sexton or Person in Charge of Premises G Y:) \2—L &R-A N
z (please print) _
Signature �-/�� Title L,.AX A f"U t
(over)
DOH-1555 (9/98)