Qua, Donald H NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
............. .D .. ... ...: � :u . ....... ....... ....-..... .
Date of Death 0 2 p® Age / If Veteran of U.S.Armed Forces,
v( J �l /.�..::....:...: f......... . War or Dates N
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Place of eath Hospital Institution or
MI: City Tv� a 7ccident
Street Address
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C Manner of Death ndetermined:... .......Pendin Natural Cause ❑Homicide ❑ Suicide g
Circumstances Investigation
lt1 Medical Certifier Name Title
..Al 5 , . , ......... ..... ............ ... .. .. ....
_
Address
..:....:..:....:..:.........:..:.:.:.::........ ,..: s
Death Certificate Filed District Number Register upmber
City,TGarn-eiL-fi ;3ge-,
Date Ce etery or Crematory
❑Burial
............I'll......... ........, . ,- .. ...v... z- .�- � -� ... .
[Cremation Address . -(
__. Lam. , .. ........... _ vim ^
Z Date Place Removed
O, ❑ Removal and/or Held
1- and/or Hold .:::................ ............. ..... ... -::: ::... _.:::::
Address
0......... :::::::.::................:..:...:.:::. ....: :.:.......................... .:: _.....
C Date Point of
Ln ❑Transportation by: Shipment
in Common Carrier .:.: .............. ............. .......................::.............................
Destination
...
❑ Disinterment Date Cemetery Address
............................... ..........................: . ..........................................
El Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Firm r Q7 z-7
Addr s _ _ ..
:........................................ ....:::. rf�. -:. :. �"_
..... ...
Name of Funeral Firm Making Disposition or tb Whom
Remains are Shipped, If Other than Above
....... ............:.......:............::......................:....... .............................- ... ................. ......... ......... ..... ...............
�! Address
Permission is h reby granted to dispose of the hum s� ndicated.
Date Issued J o< Registrar of Vital Statistics �J
(signature
<' District Number �� � Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition `o�/—9L Place of Disposition /1157/
uJ' (address)
W
(section) (lot number) (grave number)
CC
p Name of Sexton o Person in C rge of Premis s
Z please print) p �'
w' Signature Title1�"�/ / .ii �/ '
DOH-1555 (10/89) p. 1 of 2 VS-61