Becraft, Martha NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First Middle Last 11 Sex
Date of De h Age If Veteran of U.S.Armed Forces
War or Dates
.............
2? y y...............:. ..
Place lReaik �. Hosp ital, Institution or
WCity, own r Village ♦cow . the Street Address �� �,� ,,f,,,
.....
Q Manner of Death Undeterm�ed Pending }
Natural Cause ccident Homicide Suicide
........... ....::.......:..
Circumstances Investigation
Medical Certifier Name Title}�,,
10
... ........ .. .
Add res / + /� ��
........:.....C.11. tJ o� .....:..t ..::.:...............1 c�•,�Vcro x. ..............................................................
Death Certificate Filed �_ District Number Register Number
City ow�n>r Village l� C-o r. r u o
Date Ce tery or Crematory
❑Burial €
....................... 2....../ f........ ....... ..: ...... .. : Y.:.1./1.R...... .. t.fG!!!!.......... . *.,.`. .:....
Cremation Address j 1
........ �C!'N a...�.r
Z Date Place Removed
2 DRemoval and/or Held
H-' and/or Hold ..:................ ... ...... .. ........__ ............................................. ..... ..... _...: ...:..... ...........
Address
I N''
O ::::::::...........:........................::......... ....... .. . ::::::: . ...... .......:. .... ........ .......... ...... . ...... .............
OL Date Point of
cn ❑Transportation by Shipment
p' Common Carrier . .. ........ ..:::: ......... ........:::.
Destination
....:. .......
Disinterment Date Cemetery Address
El .. _ .... : ............. ....... .......- .......... ...... .........
Reinterment Date Cemetery Address
El Permit Issued to �.► Registration Number
Name of Funeral Firm Hr��� ��
l l . o s 7
...... ...............................
Address �/J .........................................................
.................................... ..........V...........
................................... ......
Name of Funeral Firm Making Disposition or o m
$ Remains are Shipped, H Other than Above
.........
.........................:.:.................................................. ...... . :......:..: ..... _ .....:::: -::::::.:
ut>
Address
G
X.
Permission is hereby granted to dispose of the human remains described above as
in ' ted.
Date Issued Registrar of Vital Statistics „/•
(signature)
District Number _ � Place d O �-Co
qJ
I certify that the remains of
the decedent identified above were�disposed
,ooff in accordance with this
permit on:
Z Date of Disposition / � / Place of Disposition�f�/7���!//�`'�
W (address)
W'
Cl) (section) (lot number) (grave number)
CCf j /fin /�
pName of Sexto or Person ' Charge of Pr mises �FZ J b-f� 7 l A
Z (please print)
LU Signature Title
DOH-1555 (10/89) p. 1 of 2 VS-61