Wolfe, Richard NEW YORK STATE DEPARTMENTOF 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
Z: Place of Death -DYHospital, Institution or
W; City,Town or Village Street Address
.
.61 Manner of Death : ::::. _... Undetermined:... Pending
Natural Cause Accident ❑ Homicide ❑ Suicide g
Circumstances Investigation
..... ........ .. .....
W.
Medical Certifier Name Title
`.
Address
.......................
- ::
Death Certificate Filed District Number Register Number
City,Town or Village
y` ,:I�N E C T A. g
Date Cemetery or Crematory
❑Burial _ y
... :.::. .::..:. t,'fir : : lf'. c....................... ...........................
Cremation Address
Q.l .':s ��
Z Date Place Removed
O ❑ Removal and/or Held
h- and/or Hold .......... ......._:... ..... .
Address
Fn
O ... .... . ....... .....:.:. .......
CL Date Point of
L ❑Transportation by Shipment
p Common Carrier ....... .....
Destination
❑ Disinterment Date Cemetery Address
......... ...... ............................... ..,....... _ .... .
El Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Firm r� .. _... ......
Adds res
77: Name of Funeral Firm Making Disposition or to Who
Remains are Shipped, If Other than Above
........ .................................. .... ........
�. Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued Registrar of Vital Statistics
(signature)
District Number Place S C H E N EC TA n v
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
F t � �s �,r
Z Date of Disposition Place of Disposition /�.� .�� Cs,�.F� i '1d'o
2 (address)
w`
N (section) (lot number) (grave number)
c
°p Name of Sexton r Perso in Charge of Premises
Z (please pent) i
w Signature Title
DOH-1555 (10/89) p. 1 of 2 VS-61