Buechner, Elizabeth NEWYORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Biostatistics -Vital Records Section
Name First M Lastsex
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Date of Deat - .........................e ..:.............. ...If Veteran of U.S.Armed Forces,
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o Dates
Z'. Place of Death r Hospital, Institution or
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Cause of Death .................. ................. . .. ... .........
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Medical Certifier Name Title
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Address
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Death Certificate Filed ' ' n :: DistnNumber Regi er Number
[ -Q4y Town
Date C tery or mato
❑Burial
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Cremation Address `�
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2 Date 'Place Remo ed
0i ❑ Removal and/or Held
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and/or H ...................................................................................................................................................................................
F- old .............::::. ................
Address
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tlDate .'Point of...............................................................................................................................
[]Transportation by:' Shipment
Common .................
O mon Carrier '
Destination
.........................................: :::Date:,:::......................................................
❑ Disinterment Cemetery Address
........................................:.:.:::Date:::::..................................................... ..............................................................
❑ Reinterment Cemetery Address
Permit Issued to
Registration Num er
Name of Funeral Firm
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Address
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f_; Name of Funeral Firm Making Disposition or to WX
Remains are Shipped, If Other than Above
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Address
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Permission is hereby granted to dispose of the h 7r3n re a' s j�d�scri a above as indicated.
'i Date Issued "01 Registrar of Vital Statistics
�-' (signature)
District Number Place
I certify that the remains of the decedent identified a ve were disposed of in accordance with this permit on:
w Date of Disposition/ Place of Disposition %S(,C 7e L B1
(address)
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(section) (lot number) (grave number)
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p.: Name of Sexton, r Person in harge of Pre 'ses
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Signature Title -�-
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DOH- 1555(9/86)p 1 of 2(formerly VS-61)