Baxter, George NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle LAS
t Sex
Date of Death Age If Veteran of U.S. Armed Forces,
7 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Street Address
Manner of Death Natural Caus ci nt Homicide ❑Suicide Un ermined Ti
Pending
Circumstances Investigation
Medical Certifier Name Tit
Addres
Death Certificate Filed istrict Nu ber LJ Register Number
City, Town or Village
Date 1JI Cemet or Cre story
0 Burial j
Address
i,L`.I t rc^^n^:atiCiri
Date Plac emoved
Z❑Removal and/or Held
-• and/or Address
Hold
0 Date Point of
NTransportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home � � ���/
Address
Name of Funeral irm Making Disp6sition or to Whom
Remains are Shipped, If Other than Above
Address
A.
1:14-
>: Permission is here y granted to dispose of the human rc ains,�Iscribed oHve s indicated.
Date Issued ° j 7 G� Registrar of Vital Statisti-,s
_ ---
(signature)
District Number Place
I certify that the remains of the decedent identified above were disposed of in accordanc with this permit on:
Date of Disposition a-G' Place of Disposition e ' t//e 4/ G m T Iq J
(address)
cc t/J
(section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises
g (please print)
1L1 Signature Title
DOH-1555 (10/89) p. 1 of 2 VS-61