Campbell, Sylvia NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First ( Middle I Sex
�J ' L✓/14.. _ i4 Ifs P I?C LL
y ....... ...:
...... ....
Date of Death Age If Veteran of U.S.Armed Forces
p� War o..Dates
k Place o eath � } Hospital Institution or
City own r Village C�'�°� pf Street Address �� ,��/on f 4
Manner of Death ... ..:. ::: ... -:: .: Undetermined..... .. .. ending
_ ..
Natural Cause Accident Homicide Suicide U Pe
W; Circumstances Investigation
.... ... .................:.:...... .....:..:.:........... .. ......... ....... ... ........ ...... . ......:. _.....
.......:... .
- .
w Medical Certifier Name Title
_::.:..
Address
SI� A 'ffC..: 'IK� _.......
. _.
De��Townrr
cate Filed ) D` trict Number Register Number
Cit Village
D(IJ� C3
Date Cemetery or Cremator
❑Burial / y� 1`'/../1. .(�/.� �c:..... .. c`/IE7/9�?0 ........ ..
,Cremation Address
11t...... !"` N : .:':::.... .... ........ .......
..:.::
Z i Date - / Place Removed
O Removal and/or Held
1-- and/or Hold .... .......... .. ... .... ... . _:::::.. .......-. ........
Address
>N
.... ......: : ..... .
a Date Point of
N Transportation by Shipment
p Common Carrier .................. .... ....................
Destination
...._..... ...................... ........ ......... ......... ................ ..
Disinterment
Date Cemetery Address
..................................... ........... _..... .......
Reinterment Date Cemetery Address
El Permit Issued to Registration Number
Name of Funeral Firm zz( ✓',
............. C... ...., '-� .U` S ,_ :. . �Js.. .L.G .. ..,� l 3...S ...,
Address
.. .......................................
t-. Name of Funeral Firm Making Disposition or to om
Remains are Shipped, If Other than Above
te.....................
.. ............................................. . ........ ................- .:................. ...
W
Address
..
Permission is h reb granted to dispose of the human remains described above as indicated.
Date Issued 3� l Registrar of Vital Statistics
r (signature)
District Number J Place �V-
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition �� Place of Disposition /.�Gl VZ �f !CJ//ll
2, (address)
W
Cn (section) (lot number) (grave number)
cc
pName of Sexton on Person , Charge of Pre ises
Z (please print)
w, Signature Title
DOH-1555 (10/89) p. 1 of 2 VS-61