Beebe, Mavys NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle La Sex
Date o Death Age If Veteran of U.S. Armed Forces,
War or Dates66
Place of Death Hospital, Institution or
City, Town or Villag l Street Addres S
Manner of Death Natural Cause Accident Homicide Suicide Undet rmine Pending
Circumstances Investigation
Medical Certifier Name Title�Sc/ n
An
r
Address .
e C ae z'sk, f�z
Death Certificate Filed District Number Register Kumber
City, Town or Village ^ `6, Q 3
Date 02 Cemetery or Crematory
❑Burial / r°
Addres p I�/I promo+inn ` vl -eA- !`L (V
`r
Date Place Removed
8❑Removal and/or Held
-• and/or Address
0
Hold
Q Date Point of
a- Q Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to / Registration Number
Name of Funeral Home
Address
P1,
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is he eby `wanted to dispose of the human remains desc ibed ab ve sin to .
Date Issued 020� Registrar of Vital Statistics GAL
(signature)
District Number Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
z Date of Disposition 2-49-f Place of Disposition j n/r��t ��1 G(ze-,44 f , ' 1 (�AA
address)
iu
(section) (lot nu ber) (grave number)
GName of Sexton or Person in Charge of Premises Lf �{-
g (please print)
t4 Signature Title wit lz
(over)
DOH-1555 (9/98)