Harris, Paul NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
_ I�iGLE
Age If Veteran of U.S. Armed Forces,
Date of Death 9
iw War or Dates
Place of Death Hospital, Institution or
City, Town or Village _- ' r
Street Address j -
Manner of Deatha Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Address
_... . _:...i._.t.. t Death Certificate Filed District R Number egister Number
City, Town or Village
:.:.
Date Cemetery or Crematory
LI Burial _i
r� - . , _... _
Address
Cremation i
Date Place Removed
g Removal and/or Held
❑and/or Address
Hold
Date
Point of
[�Transportation Shipment
by Common Destination
Carrier
Date Cemetery Address
Disinterment
Date
Reinterment Cemetery Address
€€€ Permit Issued to Registration Number
II: Name of Funeral Home
Address
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granged to dispose of the human r mains described above as indicated.
Date Issued,:. ,., ,• ,-, Registrar of Vital Statistics
(signat )
District Number, Place
'TST7
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
r
Z Date of Disposition ` Place of Disposition '�1,/��//,ZF 4J c �
W. (address)
Uj
(section`) ,q (lot number (grave number)
GName of Sexto or Person in Charge of Premises 1—e5- ✓IfD �.0
a (please print)
Signature Title d
DOH-1555 (10/89) P. 1 of 2 VS-61