Carter, Nelson R NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name Ftilj J le Last Sexc
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Date of Death Age If Veteran of S.Armed Forces,
L� y� Wa
r or Dates
Place of Death Hospital, Institution or
W City Tewa.e��Mlage 5 Street Address —/��� �' �� Pc?j � f
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W Manner of Death atural Cause Accident Homicide Suicide Undetermined Pendrig
Circumstances Investigation
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Medical Certifier Name T...... .. ........ ....................itle
................................................................................... ........................
Address C
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Death Certificate Filed District Number Register Number
City, i age . S
Date ` Cemor Crema r
El Burial
Address -r
remation[(d L-/
G . ::... -:::
Z .... Date lace Removed
O;, ❑ Removal and/or Held
1- and/or Hold ........ ........................... ....... .................... .....
Address
0.... a
.:... - :...:...................................... . ... ....... ......... . .......................
a< Date Point of
cn []Transportation by Shipment
plCommon Carrier .....::. ... .::::.......:.......:......:... .. ...... ....:::.:
Destination
......................
❑ Disinterment Date Cemetery Address
❑ Reinterment Date Cemetery Address
Permit Issued to P
[� Registratio�Number
Name of Funeral Firm i K F ( h<=i
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Addressn; l 4' �� ��. __..... ....
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#-. Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
...............................:....................... ... . ........::..::.: ..............:. _..:....::.:
Address
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.. ..... .. .. ....::.:: ...... . ..... ..::: : ......
Permission is hereby granted to dispose of the human ma' s de rihad abo as indicated.
Date Issued �' Registrar of Vital Statistics �1 ( �-
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District Number Place
I certify that the remains of the decedent identified above were
disposed of in accordance with this permit on: /J
Z Date of Disposition 4 Place of Disposition / // �f,CCiJ' �/4�/ /if 7 jzF
2 (address)
W.
Cn (section) (lot number) (grave number)
cc
p Name of Sexton or Perso i Char a of remises
Z JF (please print)
W' Signature Tit le
DOH-1555 (10/89) p. 1 of 2 VS-61