Loritts, Marion NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First P4iddle Last Sex
Date of Death Age If Veteran of U.S. Armed Forces,
War or Dates No
Place of Death Hospital, Institution or
City, Teat11 -1-Villa�e�'�gT � _ � S Street Address
Manner of Death Natural Cause ❑Accident ❑Homicide ❑Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
u Q
Address
—[
Death Certificate Filed District Number Register N m y
City, cRTo Jon!"S G (P
Date GemA
tery or rematt rry
❑Burial C' . � L( � if� Nt_ lltu-) Keotirq
Address
Cremation
Date Place Removed
Z❑Removal and/or Held
-• and/or Address
Hold
O Date Point of
NTransportation Shipment
Gl by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home PIRO 04-if 0i6*47
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/remains scribed*ove indicated.
Date Issued i� 15 �� Registrar of Vital Statistics
r (Si mature
District Number SO Place C
r
I certify that the remains of the decedent identified above were disposed of in accor ance with this permit on:
W. Date of Disposition v Place of Dispositionn/v !/� G�,/
(address)
f 1a
N
>> (section) number) (grave number)
O Name of SextorL or Person in Charge of Premises � �T T
� - (please print),,,,..�
lJ Signature t`'' Title / r
DOH-1555 (10/89) p. 1 of 2 VS-61