Owen, Kathryn NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Biostatistics -Vital Records Section
Name First Middle Last S
Q 1°l
Date of Death Age K Veteran of U.S.Armed Forces,
War or Dates
. ........................................................................
Place of Death Hospital, Institution or
City,Town o illa a (,� t Street Address j
Cause of Death
1................................ .......:.. . }�1
: . ' ... r teAr
Medical Certifier Name Title
e .... ...................... ::..
Address
:::......: : :..:::::::::
.... ..... fi . .
Death Certificate d District Number : Regis er Number
City,Town or 'la ean V12L
Date CeN tory or Crematory
El Burial
Cremation
Address
u
............. ....... . ...................................... ..................
....................::::::::::::::::..................................................:.:::::.:.
z:: Date Place R.moveg
+Qi ❑ Removal and/or Held
and/or Hold :::::::::::::::::::.:::::::::::::::::::::::::::::::::::::::::..:::::::::::::::::::::.>:::::::::::::::::::::::......:::::::::::::::::::::::.:::::::::::::::::::::::::::.::: .........::::::::::::::::::::::::::::::.....::::::::::::
Address
::::::::: ,:::::::::::::::::::::::::::::::::::::::::::::::::::..:::.:....................................................................................................... ...
QDate Point of. ...........................................................................................................................
f✓3 ❑Transportation by Shipment
Common Carrier .............
Destination
:::Date:::.::..................................................... ...........................
❑ Disinterment emetery A ress
.....-................................:.>:::Date::::..................................................... .................................................................
❑ Reinterment emetery A ress
Permit Issued to
Registration Number
Name of Funeral Firm
r r 0 le
Address
... ....... ................................... ........................................... ........................... .. ..........................,............ ..........................
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission Is hereb granted to dispose of the humAQ remains described o as Indicated.
Date Issued9A Registrar of Vital Statistics
(s' n re) _
j
District Number Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
F- -7
w Date of Disposition / — oZ Place of Disposition f /(i{t�
2.
(address)
w
(section) (lot number (grave number)
Ar
o 1�T1
p; Name of Sexton or Yerson in C arg a of Premises
Z lease
print) _
tt1` Signature Title l' � /l'�' S/
DOH-1555(9/86)p 1 of 2(formerly VS-61)