Milton, Constance NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex.-
........................ ................................. ....... ........................................................... ..........................................
Date of Death Age If Veteran of U.S.Armed Forces,
War or Dates
............. .... . ... ........-...... ..........
..................... .............................................
Place of Deat Hospital, Institution or
City,T&Aesk�6fte Street Address
.:Uj ........................ ........ ....... ....... Pen
. .... ......... .........
................ ......................................................-.......... - ..
rin in...e'a.............
El Homicide El Suicide Ei=nde"'t,=6 Ei en;ngIIJJ
Manner of Death a r Natural use Accident
Circumstances Investigation
. ................................................ .......
........... .... ....... ............................................................ ............................................
Medical CeOier Name Title
...... .....
.....................................................................................
........... ................................................ ........................... ........................
...... Address 1,7
..................
�Vg . ..... ... .................
........... .......... . ................... ............
District Number egister N er
Death Certificate*Fill;
City,Town or Village
Date C emgApry or Crey
E]Burial 'pt?ry
0
. ........................
...... ..... ............................................. .....
...Jo................ ...... ... ..........
Cremation Address
.............. .... ..... ... ...... ........... . ............... ............. ........................................................................................
z Date Place Removed
0 El Removal and/or Held
and/or Hold ...... . .......................................................................................
Address
0.... ........................................... ............. ..........................-........-...............-........................ ...... .................. ............................
(L Date Point of
Cn F1 Transportation by: Shipment
CommonCarrier .................... ................ . . ......... ................. ...........................................................................................................
Destination
..................................... .......... ........
Date Cemetery Address
El Disinterment
.......... ......I.......................................... .........................................-........... ............ ................................................................................ .......
I Date Cemetery Address
Reinterment
E]
Permit Issued to Registration Number
........................- ........... ..............................
Name of Funeral Firm
.................. .............. ..............
Address
. ...........
......... ...............j......................................... ......................... ...JIM............... .................. .............-1// .. ...../ I........ ......
Name of Funeral Firm Making Disposition or to
Remains are Shipped, If Other than Above
.......... ....... ..... ....... ........ .....
. ............................................................................................................................................................................. .......................................................................................
Address
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d2 'dPermission is hereby granted to dispose of the human r scribe 0 dicated.
Date Issued Registrar of Vital Statistics—
(signature)
District Number Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
zDate of Disposition Place of Disposition
(address)
LLJ
(section) (lot number) (grave number)
0
0 Name of Sexton Qr Person i%Charge of Pre ises
z lease print)
W A�f �ZFZ
Signature 4A"'V-j Title 4f-��
............ ..................I........ ........... .......................................
..................... .....................-.1-1..............I................ ........ .............
DOH-1555 (10/89) p. 1 of 2 VS-61