Wideawake, Mary NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
Burial - Transit
Name First Permit
Middle Las
Date of Death S
p Age If Veteran of U.S. Armed Forces, a�
Place of Death 9 o War or Dates
City, Town o 'I►a Hospital, Institu i
Manner of Death t6/, Street Address �Gu FYI '
Natural Cause Accident ne r
Homicide Suicide Undetermined Pendin
Medical Certifier Name r Circumstances Investigation
rin r1tle
Ti
Address
Death Certificate Filed ` ' Qn V1
District Numb City, Town or V a a77 Regis Number
Date
❑Burial �g Ceme y or Crematory
Address
Cremation h15 /j 1'
Removal Date Plac emoved
�❑
and/or gddress and/or Held
Hold
Date0. sportation Point of
N Q Tran
b Common Shipment
Y Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to
Name of Funeral Home i Registration Number
Address
Name of Funeral Firm Making Disposition or to W om
" Remains are Shipped, If Other than Above
Address
Permission is he eby ranted to dispose of the human r
p ' s described above as i ated.
Date Issued U Registrar of Vital Statistics
gn
District Number J Place T
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
f-
W Date of Disposition �- Place of Disposition
Ui (address)
gName of Sext n or Person in Charge of remises (section) (lot tuber ) (grave number)
W Signature (please print) L�f
Title
DOH-1555 (10/89) p. 1 of 2
VS-61