Railton, Bernice NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Idle Last Se
A E I?A) JS oN
Date of DeathZ 4/ QQ Age If Veteran of U.S. Armed Forces,
War or Dates d
Place of D ath Hospital, Institution or
City, Town or Village /. leh` f LA CIP Street Address
Manner of Death ®Natural Cause ❑Accident Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name Title
Address
Death Certificate Filed District Number Register Number
City, Town or Village , /L �'Lrq e_lp
Date j Ce tery or Crematory
❑Burial /L 2 (a` ! ell
Address
Cremation fm-t 00C' z'" // ,
Date Place Re oved
Z ❑Removal and/or Held
•• and/or Address
Hold
Q Date Point of
N ❑Transportation Shipment
by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home /� L�/ �/� /rtjC co I
Address
27 JA AA/11/4 c 4 1/c-'
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
JA Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 2 Registrar of Vital Statistics
(signature)
District Number Place
I certify that the remains of the decedent identified above were dispose of in accordance with this permit on:
W Date of Disposition Place of Disposition 4fl ��
2 (address)
iU
N
(section) (lot nu pgCl grave number)
GName of Sexton or Person irTiCharge of Premises
F (please print)
Signature, Title
DOH-1555 (10/89) p. 1 of 2 VS-61