Daniels, Howard NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle st Sex
Date of ath Age _ If Veteran of U.S. Armed Forces,
d/ War or Dates
Place of Death Hospital, Institution or
City To or Village Street Address
Manner of Death Natura ause ❑Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier �ame ,} ) Titl
Address
ZZ 3,:;�-
Death Certificate Filed // District Number Register Number
City, wn r Village
Date Cemetery o emator r`
�.��t.:
❑Burial
Address
Cremation /1
2 Al
Date Pface Removed
8 ❑Removal and/or Held
.r and/or Address
" Hold
0
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 � Z-)-U
Address
Name of Funeral Firm Making DisposiqDn or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human rem ins described above as indicated.
Date Issued Registrar of Vital Statistics
(signature)
District Number 67 Place r
I certify that the remains of the decedent identif i4 above were disposed of in accordance with this permit
on::
W Date of Disposition -99 Place of Disposition )0/F/vf!!�� /t� � /1
2 (address)
Uj
0 Leon, n� t number (grave number)
GName of Sexto or Pers n in Charge of remises,E—
z (please print) f
> Signature Title G O SS! t
(over)
DOH-1555 (9/98)