Mathias, Donald NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
LEE, S
Date o eath Age / If Veteran of U.S. Armed Forces,
L'T► o� (o °ti l0 War or Dates to 3 N (�U
P e of Death Hospital, Institution or
City Town or Village LL Street Address I.L S OS
nner of Death atural Cause Accident ❑Homicide Suicide ❑ Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name Title
Addres
o �2 GtE s LDS 12'b� l
ath Certificate Filed District Number Register Number
it , Town or Village - {� Lt. ��� ���'
Date q Crematory
U burial
Address
Cremation u�� U E Ctj
FDate lace Removed
0❑Removal and/or Held
-• and/or Address
Hold
Q Date Point of
Q Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home ��Q it N C , O l
Address
Name of Funeral Firm Making Disposition or to Mom
Remains are Shipped, If Other than Above
ja Address
Ilk
Permission is hereby granted to dispose of the human remains des ribed bov s' c d.
Date Issued 16) Registrar of Vital Statistics r
/ (
signature)
District Number Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition�� Place of Disposition /r 6601
(address)
iq
N
(sec on of number) (grave number)
GName of Sexton or Person in Charge of Premises
(please print)
Signature Title
(over)
DOH-1555 (9/98)