Rooke, Helene NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middy ast S
Date of Death 9 Age / If Veteran of U.S. Armed Forces,
(� War or Dates
Place of Death Hospital, Institution or
City, Town or Vill �" "`' 'I' Street Address
Manner of Death atural Cause ❑Accident ❑Homicide ❑Suicide ❑ Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name Title
Address
Death Certificate Filed District mber Regis Number
City, Town or Vi I � � y
Date A
Cemetery rematorBuri
Address
Cremation
Date Place Removed
❑Removal and/or Held
and/or , Address
Hold
0 Date Point of
❑Transportation Shipment
by Common Destination
Carrier
❑Disinterment Date Cemetery Address
I
❑Reinterment Date Cemetery Address
Permit Issued to Registration Nymber
Name of Funeral Home ,/f.�� to /Qp b
Address
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Ilz
Permission is her by granted to dispose of the human ins scribe bove as indicated.
Date Issued ,� cz��
Re istrar of Vital Statistics �ti�x- —'
9
signattuurre)
District Number Place eMc � 4 =
1 certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition Place of Disposition
da dress)
Moll
N
X (se tion) t numb_ (grave number)
GCyName of Sexton or Person in Charge of Premise 1�
Z (please print)
Signature G Title
(over)
DOH-1555 (9/98)