Beaver, Mary 3-jk 9
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name��i� Middle Last x
Date of Death Age If Veteran of U.S. Armed Forces,
- War or Dates /Z
Place of Death Hospital, Institution or
Cit Town r Village , Street Addressyt d.
Manner of Death F1 Natural Cause Accident ❑Homicide ❑Suicide ❑ ndetermined ❑Pending
Circumstances Investigation
Medical Certifier Name Title
1�1
Add ss ..,
=V�e
Death Certificate Filed District Number Register Number
Cit Town r Village
Date I 1 Cry
❑ ycmrtoryBurial c
Address
Ekremation
Date Place Removed
8 ❑Removal and/or Held
-• and/or Address
Hold
Q Date Point of
❑Transportation Shipment
by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Z'IkuSA ( .
Address (.
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human reins decri d above a_si ' ted.
Date Issued i� 3 Registrar of Vital Statistics r Pam"
( nature)
District Number,!205CO Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
t2 E l�- U
Date of Dispositions Place of Disposition _ / U/L'7
W.
(address)
UJI
W
(section) I t number (grave number)
CName of Sexton or Person in Charge of Premises '�—
g (please print
Signature TitleL C, r-1�'Z ►�"���'� /
DOH-1555 (10/89) p. 1 of 2 VS-61