Oliver, Rose NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name Fir Middle Last Sex
Date of Death Age If Veteran of U.S. Armed For
j 9`'7 War or Dates 4
Place eath a HC Hospital, Institution or ,✓
Cit own o Village Street Street Address
Manner of Death®Natural Cause 0 Accident Homicide Suicide Undetermined El Pending
Circumstances Investigation
Medical Certifier Name. Title
Addre s
42
Death C icate Filed District Number Register umber
City, own r Village
Date..�— C etery or Crema y
❑Burial /99 71�12 ili�cc� i�t� [
Address
,Cremation
Date Place Removed
❑Removal and/or Held
0 and/or Address
Hold
Q Date Point of
Q Transportation Shipment
fl by Common Destination
Carrier
Disinterment Date Cemetery Address
Renterment Date Cemetery Address
Permit Issued to Re gistration Number
Name of Funeral Home
Address
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 remairjs describ bove as indicated.
Date Issued `Z97 Registrar of Vital Statistics ��
si nature)
District Number Place l C
I certify that the remains of the decedent identified above were disposed of in a rdance with this permit on:
z Date of Disposition "/ Place of Disposition A A(le— Yj.EJ ��'.��1��
W (address)
iTJ
tl�
(section) (lot number) (grave number)
flName of Sext or Person in Charge o Premises ",��f/%�fa
zZ (please print) /
W Signature Title SS !
DOH-1555 (10/89) p. 1 of 2 VS-61