Pond, Walter NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex�
0
Date of Death Age If Veteran of U.S.Armed Forces
War or Dates A16)
P ...... ......... ......................................................... ..::
...
Z Place of D th jj LL //�� Hos ital, Institution r
LU City,Town or Village If./ZAU e 7`•�j}�c}WAI Street Address p/,gee 2 /7 0�t�
G Manner of Death :: _:::: _ ......... : ...... .U..d....ermined . Pending.. .:::::.
W Natural Cause Accident Homicide Suicide ❑
Circumstances Investigation
W Medical Certifier Nam / Title
�a z..
<> Death Certificate Filed District Number Register Number
City,Town orVillage,�i--/—/ZPf71l�/nJ
Date ,. Ce��etery or Crematory
❑Burial S �y::..... ...... /wt::rO�t�r✓.:... .
........... .. .. ..
®Cremation Address ��
.:: _ ....
Z Date Place Removed
O ❑ Removal and/or Held
F- and/or Hold ::::::
Address
O _: ..:. ....::::
a Date Point of
v7' ❑Transportation by Shipment
p Common Carrier .:......... . _.:. :: ..:_.:_
Destination
❑ Disinterment Date Cemetery Address
Ad Date Cemeterydress
El Reinterment
Permit Issued to Registration Number
Name of Funeral Firm ��2�//NS'
_ G A......... .....
Address
1�7 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 remains described
a�boovve� as indicated. /
Date Issued Registrar of Vital Statistics ' /7' // �QrU1/`i'� Z4�v .
(signature)
District Number �SS�vz Place -�uJ�
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W' Date of Disposition o7�S� Place of Disposition i/1;'PA04 0,,eq!/yW
2 (address)
w'
N' (section) (lot number) (grave number)
cc
°
p Name of Sexton o Person in arge of Premise
Z lease print) �� HI� Y ♦�
W Signature Title r
DOH-1555 (10/89) p. 1 of 2 VS-61