Brundige, Frank ,__W€W YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name Pit
Mje st Sep%y'
Date of Death Age If Veteran of U.S. Armed Forces,
�j /e7 �S` War or Dates
Place of Deat l Hospital, Institution or
City, Town or Villag / Street Address 2z-
Manner of Death Undetermined Pending
Natural Cause Accident Homicide Suicide ❑Circumstances Investigation
Medical Certifier 19t1e
A dress
Death Certificate Filed District umber / Register i(jynb
City, Town or Village
Date Cemetery or Cr ory,
❑Burial
Addres e
Wremation i
Date Place Remo
z❑Removal and/or Held
and/or Address
Hold
Date Point of
F_�Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to i Registration Number
Name of Funeral Home
p ,
Address / Z�
Name of Funeral Firm Makin Disposition or to Whom
Remains are Shipped, If Other than Above
Address
PP�miecgn!! o. hpr h�i n! ..ta ±� o,... . 6t Sr e`iu'3te`
Date Issued Registrar of Vital Statistics
(si ture).
District Number-- �L—�� Place
I certify that the remains of the decedent identified ve were dis ed of in accordance with this permit on:
Date of Disposition Place of Disposition
(address)
Q0 (section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises
(please print)
Signature Title
DOH-1555 (10/89) p. 1 of 2 VS-61