Biehl, Kingsley NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
<A ......... ..... ....................................-..............
................ ................................
Date of Death If Veteran of U.S. Armed Forces,
Age
......................... ...........
.....3..—...... ..... .......... .. .......................................... ...... .......... War o.. Dates
Place
...............
..................................................................................................................................................
.1 � Place of Death Hospital, Institution or
-.W: City,Town Street Address
or Village s 1'�
...................................... .............
.......... ....... ...... ........ ............................................... ................... .....................................
Manner of DeathLLLJJJ
El Suicide o Undetermined E] Pending
Natural Cause Accident Homicide
Circumstances Investigation
........................................ .....................
Medical Certifier Name Title
.................................................. ......... .......................................................................................................................-.......................-
Address
...............................-
..L)i��� ........ ......... ..........Number
.......b... .............-............................................... ....................................................... .. ....
Death Certificate Filed District um er Register Number
City,Town or Village C)
......
Date Cemetery or Crematory
❑Burial
........................
,�F ...
Address
remation :
7
..................... . .. ....... ...... ....... ....................
....... .... . ...).-,
Z' Date Place Remove 0Ij Q Removal and/or Held
...........
I-- and/or Hold .......-......................... ........... ................................................ .............
...Add—..................... .......... ........Address
0-1-....................
.......................................................................................................................... ........................................................... ............. ......
CL Date Point of
to Transportation by
Shipment
aCommon Carrier ' ..." .................... ............. ....... ..........b Destination ........---........ ...................—.................. ........
........................................................................................................................................................................................ ........ ............................................... ................
Date Cemetery Address
Disinterment
El
.............................................. ...............................-........... ................................ ...... .......... ............................................
Date Cemetery Address
F1 Reinterment
Permit Issued to Registration Number
......
Name of Funeral Firm
.................................... ............... .................
..... Address
<
. .. ...... . .....................
...........�(o.......... .. C4,
...... .... . .. ...
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
.............. ---........ ....... ...... ...... ...
.......................................................................................................................... .......................................................................................... .............. .................
.: Address
.......... ................. ................................................. .................................................. .................... ...........
............................................... ...........................................................
as i
Permission is hereby granted to dispose of the humanjemains descrii d a e ndicated.
Date Issued IiIf3 Registrar of Vital Statistics
...... (signature)
S"
el
District Number Place
I certify that the remains of the decedent identified above were disposed of in ac rdance with this permit on:
W Z: Date of Disposition Place of Disposition 41
(address)
W
(section) (lot number) (grave number)
0
in Name of Sexton qA Person in,'Charge of Premises ,(FDAIXIM7
z (please print)
UJI Signature Title
...... .......... ...........-....
....................... ............-..............................................
............... ............................ .................................. ...... .........
DOH-1 555 (10/89) p. 1 of 2 VS-61