Hudgins, Mary NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle ast Sex
Date of eath / Age If Veteran of U. . Armed Forces,
War or Dates
Place of eath Hospital, Institution or
City, Town or VillageZ Street Address
Manner of Death Natural Cause ffAccidernt HomicideEl Suicide ElUndetermined Pending
Circumstances Investigation
Medical Certifier Na e Title
Address
Death Certificate Filed District Number Register Number
' '` City, Tew�-er�i�+age-- .Lfs� � a �•
Date Ce ery or C _atory
❑Burial �y -c
I Address
t cremation!
Date Place Removed
Z Removal and/or Held
and/or ( Address
Hold
0
Q Date Point of
NQ Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to , Registration Number
Name of Funeral Home 1 6y
Address
Name of Funeral Firm Making DispoCtion or to Who
Remains are Shipped, If Other than Above
Address
<. Permission is here y g anted to dispose of the human rem de c ed above i cated.
Date Issued 9 Registrar of Vital Statistics f
(sig ture)
5� Place
District Number
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition Place of Disposition /W. WV -&t,) �l��iG1�lO�r�M
(address)
i�
W
( n) (lot number ) (grave number)
� Name of Sexton r Perso in Charge of remises
g (please print) t
LTitle
Signature Ss/
DOH-1555 (10/89) p. 1 of 2 VS-61