Cubberly, Evelyn NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First M / Last S
Date of Death y� f Age r� If Vetera U.S. Armed Forces,
�i War o Dates
Place of Death +� TOGA SPRINGSstreet Addressution
City, Town or Villd
Manner of Death®Natural Cause Accident ❑Homicide ❑Suicide Unde ermined Pending
Circumstances Investigation
Medical Certifier Name Title
Addre
Death Certificate Filed i WstrictAumber Register Number
City, Town or viIIABARATOGA SPRINGS
Date Ce50ery or rematory
❑Burial �/
Addr s
Cremation
Date Place R oved
O ❑Removal and/or Held tl
j: and/or Address
Hold
0 Date Point of
Q Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to � (' Registration tuber
Name of Funeral Home —�Jiva
Address
Name of Funeral Firm Making Disposition or to Whofn '
Remains are Shipped, If Other than Above
AN Address
Permission is h�/er b granted to dispose of the human main scribe a e as indicated.
Date Issued /kd Registrar of Vital Statistics _
(s nature)
District Number 01 Place SARATOGA SPRINGS
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition Place of Disposition
2 (address)
UI
r (section) (lot number (grave number)
GName of Sextog or Person in Charge of Premises
(please print)
Signature Title
DOH-1555 (10/89) p. 1 of 2 VS-61