Calcagne. Raymond NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
>' Name Firs fiddle Last Sex
o 4 �-
>: Date of Death Age If Veteran of U.S. Arme s,
/ War or Dates A)
Place of Death Hospital, Institution or
City, Teucct e S CGS Street Address z':5vs
Manner of Death Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Addres
Death Certificate Filed istrict Number Regist r Numb
City, Tpaa�
CL�4)s �)'Ls-
Date Goxolk4y or Crematory
Address n
Cremation
Date Pface Removed
8 ❑Removal and/or Held
•• and/or Address
Hold
Q Date Point of
Im
to❑Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
gistrationumber
Permit Issued to
Name of Funeral Home L V"pwt Q
Address ��-
0 O ID l o- L - 14'A Gam, , ,
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 ruins described above as indicat d.
Date Issued U toI Registrar of Vital Statistics , Q
it / r signature)
District Number--� - Place f r►�s
I certify that the remains of the decedent identified above were dis71t;
d of in accordance with this permit on:
zDate of Disposition '-;j— Place of Disposition / � `�
(address)
LU
section (lo num Q (grave number)
GName of Sexton or Person in Charge of Pr ises, �, %7
g pl ase print)
Signature Title
DOH-1555 (10/89) p. 1 of 2 VS-61