Ridout, Gladys NEW Y0. STATE DEPARTMENT OF HEALTH
Vitaf�ecoor�ds Section Burial - Transit Permit
Name First Middle Last Sex
Date of Death Age If Veteran of U.S. Armed Forces,
— — (} War or Dates
Place of Death Hospital, Institution or
City,Town or Village Street Address E LS O
anner of Death Natural Cause ❑Accident ❑Homicide ❑Suicide El Undetermined El Pending
Circumstances Investigation
Medical Certifier Name Title
60 Q GE, cm & I
,Address
hCis �Ls m a�0
D ath Certificate Filed District Number Register Nu ber
City,Town or Village t✓L� �� 3
Date q Eeriek y-er Crematory
El Burial 03— ��� -
Address
t�Cremation I
Date Place Remove
8❑Removal and/or Held
••• and/or Address
Hold
Q Date Point of
0❑Transportation Shipment
by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home FNC ; O
Address
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
r er-nisaion i3��crcuj,yr i�tvaa 1[c "1.ap c;az of the humnan rerSYaair''s dGGCrZC su ve iia as u.
Date Issued 3 1 l�� Registrar of Vital Statistics ., � .�`�
(signature)_
District Number L5-6 Place
I certify that the remains of�the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition j-C2 Place of Disposition /�!�/�.� /.� � t.�/1✓I/� 1�ll/�
(address)
LJJ
(section) Q (I t number) (grave number)
GName of Sexto or Person in Charge of Premises
z 0 (please print) -�
Signature Title /Y(
DOH-1555 (10/89) p. 1 of 2 VS-61