Miller, Joseph NEW YORK STATE DEPARTMENT OF HEALTH
Vital Pecord;s Section Burial - Transit Permit
Name FirstJO'S
Middle Last S
Date of Death Age If Veteran of U.S. Armed Forces,
War or Dates
Place of Death Hospital, Institution or
City, Town o ill /IVj/1t, Street Address
Manner of Death ❑Natural Cause Accident Homicide ❑Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Address
Death Certificat _F_ited / District Num er Register Number
City, Town o Villa. 1)V/�CQ��_
at eC etery or Q remator
❑Burial T
Add es
11Cremation
Date Place Removed
0 ❑Removal and/or Held
—. and/or Address
Hold
0 Date Point of
Q Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to r..-., Registration Number
Name of Funeral Home
XX
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 re ains describedabove as indicated.
Date Issued c1 Registrar of Vital Statistics
(sign u e) `J
District Number � 5� Place
I certify that the remains of the decedent identified above were dispose of in accordance with this permit on:
W Date of Disposition Place of Disposition If/4
(address)
w
(section) lot umber) (grave number)
0 Name of Sextop or Person in Charge of Premises 4: �Arr-y L�
g (please print) y r
Signature Title .-!zw
DOH-1555 (10/89) p. 1 of 2 VS-61