Taylor, John NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section - Burial - Transit-Permit
Name First Middle / Last Sex
Date De thJ Age If Veteran of U.S. Armed Force , `
19
7 War or Dates 3/
Place of Death Hospital, Institution -
City, Town or Village S�� /�' Street Address
:. Manner of DeathPO Natural Caus Accident Homicide Suicide Undetermined Ej Pending
Circumstances Investigation
Medical Certifier Name Title
Add7y a
Death Certificate Filed District Number / Register Number
City, Town or Village
Date . Cemetejj or Crematory
❑Burial
Address
remation
Date Place Removed
z a.Removal and/or Held
0 and/or Address
Hold
C Date Point of
Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Re r
Name of Funeral Home
Address
14,
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission Is hereby77-7Registrar
tAd to _licnnge of±!.e hum2n re=nde- ihrb �1 ♦ma.- r. c�.i wii C Iuia.�iCal.
Date Issued j � of Vital Statistics
(sig ure)
<' District Number Place /
I certify that the remains of the decedent identified above were disposed of in accordance/with this permit on:
f� _
LLU Date of Disposition/� Place of Disposition e! N EVZ-6 / GR F_,yACoP_ ib &1
(address)
ILI
.0
M (section) (lot n ber) (grave number)
Name of Sexton or Person in Charge of Premises _(g k
g (please prin ) _
Signature t? Title 1�
(over)
DOH-1555 (9/98)