Goldsmith, Carel F NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Biostatistics -Vital Records Section
Name First Middle I ast
. / Sel�ff'�-�
—4
�._ h-f t
Date of Death Age If Veteran of S.Armed Forces,
� .War:or Dates
::::::::::::::::::......:la:c of De a- ........../....%..'....�................................
Hospital, Institution or
City,Town or Village �F Street Address
Cause of D ath /
>t33 -
-z
Medertifier Name T
:G
P
Address r
`v
............
Death,, to Filed District Number Regsfer N mbar
Cit own illage
. Date Ce tery or Cre atory
ElBurial
remation
Address
M Date s Place Remove
+O> ❑ Removal and/or Held
and/or .....................................................................................................................................
1 Hold ::::::::::::::......:::..................................
Address ................................................................................................................. .............................
jn ; Date :;..Point of................................................................................................................................
I ❑Transportation by Shipment
CommonCarrier ............................................................................................................................................................
Destination
.........................::::::Date::::::.................... ............................ ......................:..
El Disinterment Cemetery Address
........................................ .::::::at::::::.......................................................
:::>::>:<::::.........................................::::
❑ Reinterment Date CemeteryAddress
Permit Issued to Registration Number
Name of Funeral Firm r
... ....................... ........................................................................................................................
Add res
/ t
r
f fri-.- C!L7
Name of Funeral Firm Making Dis ition or to Whom
Remains are Shipped, If Other than Above
Address
Permission Is hereby granted to dispose of theme n remains desc bove as ndicated.
Date Issued Registrar of Vital Statistics
(sign re
District Numbe�s� Place K-
I certify that the remains of the decedent identified above wee disposed of in accordance with t s per-merit on:
Date of DispositionL Place of Disposition Afl✓ �"/Iek; /tf .--'P dc /l1
(address)
W
(section) (lot number) (grave number)
p. Name of Sexton o ,Person in harg a of Premises
Z (please print) �--�
W: Signature Title
DOH-1555 (9/86)p 1 of 2(formerly VS-61)