Hayward, Harold D NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Biostatistics -Vital Records Section
Name First Last
A
x
_r
Date of Deat�i� ���....................'... Q.....................:,..If Veterar/1...�t...:: �.,�.....r..Z.r :::::::.�:::::::::.�::::::::,.
g of y�Armed Forces4, _
War or Dates ...................
Place of Death Hospital, Institution
........... ..........................
j_ City,Town or Village Street Address
r�........... �....... �...... ...
t Cause of Death
:::......:..::::::::::::::::::::,::::......:::::::::::::.::::..........................................................................
Medical Certifier Name,-.._ .. - Title
�___ .
a
Address— !i ,1 ..... f�.... . .....,.../..'r.. !
f ..,
Death Certificate Filed — �. District N umber / Register Number
City,Town or Village
Date etery or remato
❑Burial - `
Cremation Address
.: . :.. . : ....................::::::::.::.::........::
ZI ........>: : ..... : . : .
::.. ::. ::: .................1.1. . .. ..... ::.....Date Place Rem fe(d
0 ❑ Removal and/or Held
1, and/or Hold ::.Address.........................:.:.............
.::.....................;.::::.............:...:...............:.....:.
Date Point of
mil. ❑Transportation by.. Shipment
Common ...................................................................................................................................;p: Carrier ..:::.:.:..........:..:..:......
Destination
.............:..:..........................................::...................::...::::.....
❑ Disinterment Date ; Cemetery Address.:.:....................................................................................................
.............:.:::::::.::.:..............:::...:................::::.::::::.:.....................:.::::................:..::::..:...... ....... .. ........................................
❑ Reinterment
Date : Cemetery Address
Permit Issued to Registration Number
Name of Funeral Firm
_N 7
Address
fn ,
Name of Funeral Fir Makin Disposition or o horn
Name i £"�`
Remains are Shipped, If Other than Above
IL.
Address
is
Permission Ismhereby granted to dispose of the huymaa remains descr bed abo as Indicated.
>' Date Issued '/ ���'/� Registrar of Vital Statistics L — y 4 / �-
- lgnature)
District Number G Place
I certify that the remains of the decedent identified above were disposed of in accordance with this�permit one: ' ,e
WDate of Disposition Place of Disposition
(address)
'w
t]NC' (section) (lot number) (grave number)
pName of Sexton Person in harge of Premis 4� � � / f 4z!!k
Z ase print)
W' Signature ' Title a
DOH-1555 (9/86)p 1 of 2(formerly VS-61)