White, Lawrence S NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
' Name First Middle () Last Sex
c
2�ti� u
Date of Death �j J Age If
If Veteran of U U.S.Armed For s
c� / / < War or Dates .:. :. ... ze
.
Z Place of Death ' 1 Hospital Institution or
City Town or Village k Street Address
....: _..
�
G�., Mannerof Death MNatural Cause Accident El Homicide El Suicide Undetermined Pending
Circumstances Investigation
.:
Medical Certifier Name z
G
V
Address ..::
/,
Death Certificate Filed District Number Register Number
City,Town or Village wtra /
Da / Cem ry r-C remal
pry
❑BurialL �. 'jam
Cremation Address
A
Z Date 4Place Remo ed
O ❑ Removal and/or Held
F-- and/or Hold .Address
............ -- ..:: .... ...... ..::..... ......... ...... :::::.......
Address
N
0.................. ........:..................... ....................__
a Date Point of
cn ❑Transportation by Shipment
p' Common Carrier ..:.:. _,::.,;....................... ........ .. ......... _ _,
Destination
...._ ......... ............... .........
❑ Disinterment Date Cemetery Address
__...:..... ....... .
El Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Firm Lj ` -... �� l
... �z...:...: . _ ... ..............
Address
_::... ......... ....... .g. po -.. _...
.
Name of Funeral Firm Makin Disposition or to Wh
g Remains are Shipped, If Other than Above
.::..: ::.::.... :..:.............::.......:............::.: ......
XIM w:
Address
Permission isp hereby granted to dispose of the human r ins described above as indigated.
Date Issued 1S ' 3 �L Registrar of Vital Statistics 1
(sign ure)
>' District Number Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W" Date of Disposition l�+/ Place of Disposition �i%�C
L (address)
;w
N'' (section) (lot number) (grave number)
p Name of Sexton oPerson Tiharge of Premi es yx&
—�^
W (please print)Signature Title /i -���7 y�-s j
elf '/��_,�_
DOH-1555 (10/89) p. 1 of 2 VS-61