Fiscus, Ronald NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Biostatistics -Vital Records Section
Name First Middle Last f Sex
Iq
............ ................... ........ ..................Date of Death Age If Veteran of U.S.Armed Forces,
............. ........ ........
War or Dates
Place of DeAth Hospital, Institution o
.Z.
City,Town er V41agei Street Address
pzI€ : &.......... ........ .....
........ ...... ... ....
Cause of Death
Medical Certifier Name Title
Address
40 ................. ....
Death Certificate Filed District Number Register Number
City, Twaillar-Jamw
Date C t e e.ery or C ato repry
....... El Burial
........ ..... ........ .............. R"J
Cremation Address-
......... ... ... .............
........ .... ...
Date Place Removed
Removal
and/or Held
and/or Hold .........'
Address
0.
.......... .................. ........
......... ....... .... .. ...
Date Point of
i! OTransportation by'*
Shipment
Common Carrier
Destination
..................................
....... Cemetery Address
O Disinterment
dd Date
I-1 Reinterment
Cemetery A ress
L-j
Permit Issued to Registration Number
0 .2 z 19 Name of Fun��a!f
............ ..... .......
im
.................
............................
Address
Name of Funeral Firm Making Di sition or
Remains are Shipped, If Other than Above
...............
Address
........... ..... ..... ....... ........ .............
.X.X.X.
Permission Is jhereb granted to dispose of the hun3-an remains described above as Indicated.
....... Date Issued 00 Registrar of Vital Statistics
s-ignedure)
....... District Number Place 157
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
-Z' Date of Disposition jr' CQ Place of Disposition A
(address)
W.
01
Z" (section) (lot number) (grave number)
0 Name of Sexton gir Person in Charge of Premises
. :
(please print)
..tv:.... JJ#....... Signature Je4"a� Title
DOH-1555(9/86)p 1 of 2(formerly VS-61)