Huestis, Rhesa NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name ir5l `` Middle Last Sex
Date of Death Age If Veteran of U.S. Armed Forces,
War or Dates
PI ce of Death Hospital, Institution or
Ci , To`�r Village Street Address
Ma of Death ❑Natural CauseRAccident Homicide Suicide Undetermined Pending
Circumstances ,-investigation
Medical Certifier Name Title
• a �✓" �dGri��l
Address
Uc✓ !v - ��
Death Certificate Filed District Number Regi r Number
City, ow or Village l� , a—
Date Geqtetofy or Crematory
❑Burial
Addr s
Q)�Mremation / o,
Date Place Removed
0 Removal and/or Held
and/or Address
Hold
Q Date Point of
Transportation j Shipment
G by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to _ Registration Number
Name of Funeral Home
Address
zr l /
Name of Funeral Firm Making Disposition or to hom
Remains are Shipped, If Other than Above
Address
Permission is here y ranted to dispose of the_hum n remains desc ' above a dicated.
Date Issued ti
/J Registrar of Vital Stati
(signature
District Number ��7—
Place pC �jTJcco
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
t
Date of Disposition —� — Place of Disposition /�t/�i��f�4)
(address)
W
N
(section) (lot number) (grave number)
GName of Sexton or Person in Charge of Premises , �4/y�/�D �1/f�/MAI
g (please print)
W Signature d�j 5_— Title C
DOH-1555 (10/89) p. 1 of 2 VS-61