Code, Aletta NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Biostatistics -Vital Records Section
Name First � Midd
r Last s Se
......::.::.......:.:. : :::::.::: a
Date of Death Age ff Veteran of U.S.Armed Forces,
' ' l
::::.:. War or Dates
E^. ::::.::::: .. ..........
Place of Death
............
Hospital, Institution or ,{
City,Town o villa �� Street Address Ti
:�:................::::::::::::::: .::::.:: . ::.......::::::::::::::.:::::..:::::::::::::::::::::::::::::::::::::: : 7, tll7............1�.�:...A, f f1�r /112�
: Cause of Death l! . .........................................:.::..:::::::::.,
:_� Medical Certifier Na 'Title
:1 a c::::::::. .t'
Address
Death Certificate d District Number : Register Number........................
City,Town or illa ° Q`'��I'
Date Cemetpry or Cremato
❑Burial ry
Cremation Address
. ........:::.:............:::..:.........:::.�::.:.........:.:..::::::....::.:.:::::....:::::::::.� ...n.. ....::::::�:y.::..:.:.:::::::::::::::..:::..:::::::::::::....::..:::::::::::::..:.:::::::::.:::::...
Z; Date :: Place Removed/ {
C1; ❑ Removal and/or Held
and/or ...........................................................................................................................................................................................
:.
H; Hold ...::...............................................................::....................................................................................................................
Address
N
Q: ::..::::::::: ............::::.::::::::::::::::::::::::::::::.::::::::::::::::::::::::::::::::::::: .......:::::::::,............................................................................
........
Date Point of
❑Transportation by
—: ' Shipment
O> Common Carrier .................................................................................................................................:............................................................
::::::::.:::::::::::::::::::.............................................:...................................................................................................................................................
Destination
Date::::::.....................................................
❑ Disinterment Cemetery Address
>::.Da4e:::.:..................................................... ........................................................................
Cemetery Address
171 Reinterment
Permit Issued to
Registration Number
Name of Funeral Firm Q�J ar j �/ g
l' / ( L �
:.;:.;:.>:
Address
^1
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
i0.
Permission is hereby granted to dispose of the human,remains describe ve as indicated.
Date Issued Registrar of Vital Statistics
(sign e)
District Number Place';) f(�r
F-
I certify that the remains of the decedent identifiedabove were disposed of in accordance with this permit on:
Z: Date of Disposition 101a Place of Disposition ,g7o� i
w
.21
(address)
;w
section lot number rave number
p Name of Sexton Person in Charge of Premises
z (please print)
Signature Title
DOH- 1555(9/86)p 1 of 2(formerly VS-61)