Podwirny, Walter NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Biostatistics -Vital Records Section
Name First r Middle Last
d Sex
V.
Date of Death Age a H Veteran of.0 S.Armed Forces,
t
>' > tee War or Da
Place of Death `_ .� Hospital, Institution..or...... .................................................... ......
City,Town or Village Street Address Z, -3 -t�, �
Cause of Death ,
Medical Certifier Nam6t,, Title
:c
...................................................
Address �.
.........:::.:tifi:.:.............::::. :..:.......:.b.::tr '..... ....... � ........ .........:::::..:....::::
Death Certificate Filed f istrict Number �� r/ - iste�Nu . r
City,Town or Village �� -
Date '� Cemeter�c�r Qremat ry
❑Burial J — — T�
MCremation Address ,
:Z: Date PI emoved
ai Removal and/or Held
and/or Hold :::::::::::::::::::::::::::::::::::::::::::::::::::,::::::::::::::.:::.,::::::::::.:.::::::::::::::::::::::::::::::::::::::::::::::::::::............:::::::::::::::::::::................:::::::::...................:::._::::..:.
Address
tL; Date Point of
u>; ❑Transportation by
": ` Shipment
Common 'r .....................................................................................,..........................
......................................
Destination
te::::::..................................................... :: Address::::::...................................................................................................
Disinterment Da Cemetery
................ ................
Date
::::::....................................................... :::::Address::.::.......... ................................................. ...........
Reinterment D e Cemetery
Permit Issued to t -7 : Registration Number
JName of Funeral Firm L`�cA7a'7/
Address
a
.. .......................................................................................................................
Name of Funeral Firm`Kifaking Disposition or to. hom
Remains are Shipped, If Other than Above
:, .....................................
1 Address
Permission Is hereby granted to dispose of the human remains described above
as Indicated.
Date Issued � � �Registrar of Vital Statistics
j (signpture) v
District Number PlaceLZ
`1 �L
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition /t277q Place of Disposition�/ C zfe 13 k z
W` ((address)
w:
tY
(section) (lot number) (grave number)
0.
a Name of Sexton Person i har e of Prer ises w (please print) �I/�'41 -T Signature Title �G
DOH-1555(9/86)p 1 of 2(formerly VS-61)