Warren Sr, Jessie NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Mid d(e Last
Date of De th Aaee If Veteran of U.S. Armed Forces,
l (i War or Dates' A/y
Place of Death /� Hospital, Institution or
City, Town or Village (� riG s �>qyL �l�.v
S Street Address (� s G.LS
Manner of Death oNatural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Medical Certifier Named Title Circumstances Investigation
Address
Kpz is /y
Death Certificate Filed District Number Register Number
City, Town or Village C-,v s A-P
Date Ceme or Crematory
ElBurial � 1/� -`. w JrJ /f'l Td
12Cremation Address
Date [and/or
ace Removed
Z ❑Removal Held
and/or Address
Hold
0 Date Point of
❑Transportation Shipment
by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to / Registration Numb r
Name of Funeral Home <.__ O/v 40 U
Address
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby rant d to dispose of the human remains described above as indicated.
Date Issued Registrar of Vital Statistics '�i2
(sign ture)
District Numb�
Place r � �
I certify that the remains of the decedent identified above were disposed of in accordance with this p ;permit on
z Date of Disposition,]_6716'/VPlace of Disposition /10/rX�li/ � (f—_/f;6-A4/yrl "
f M
(address)
i�
(section) (101 number (grave number)
AName of Sexto or Person in Charge f Premises ,ty4&/D Ally j
g (please print) ��-- �
Signature Title �%/l,E/l��l�l� / / '
DOH-1555 (10/89) p. 1 of 2 VS-61