Waite, Autumn NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First M' , Last
Date of e t Age If Veteran of U.S. Armed Forces,
War or Dates
Plac eath Hospital, Institutio o
City, Town r Village 'l.�Vll�1 Street Address
Manner of Death ❑Natural Cause Accident Homicide ❑Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Addres /� ,� yl
Death rtificate Filed Distric f egister Number
City, own r Village ( /
Date Ml�
etery o ;emat ry
Burial
:Addres
Cremation
Date Place Removed
Removal and/or Held
0 and/or Address
Hold
0 Date Point of
0-Q Transportation Shipment
by Common Destination
Carrier
Disinterment
Date Cemetery Address
Reinter
Date Cemetery Address
Permit Issued to f e istration Number
Name of Funeral Home 1
Sum
>< Address C f sc&wt'
I
Name of uneral Firm Making Disposition or o Whom
Remains are Shipped, If Other than Above
Address
s Permission is hereby granted to dispose of the human remains described above as indicated.
13 I Registrar of Vital Statistics
Date Issued
(signature)
District Number 575 Place
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition�j Place of Disposition i
(address)
W
Cc (section) n (lot um er)�j , ( (grave number)
0 Name of Sexto or Person in Charge of Premises .UWAJ /f.� ���/ /7k/
A
(please print)�t d
Signature Title
DOH-1555 (10/89) P. 1 of 2 VS-61