Davis, Marion NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First 4 Middle Last Sex
Date of Deat Age If Veteran of U.S. Armed Forces,
War or Dates l q 7
Place of DeathHospital, Institution o l
Oity�' orbiHt� ?-Mvewis
.,r Street Address
Manner of Death [natu'raf Cause 0 Accident 0 Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name a ,/ Title
Address r" OA
00�- cell
Death Certificate Filed District Number Register Number
City, Town or Village
Date I 'r CernifRV or Cre a ry
❑Burial ff
[�( ( e l �l� l.�✓P�1 W!�+-
Address
[Cremation
Date Place Removed
❑Removal and/or Held
,-- and/or Address
Hold
1.0. Date Point of
Q Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit issued to Ret�tio�y�q�ber
Name of Funeral Home �� �� q
Address
tha
Name of Funeral Firm Making isposition r to om
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains cribed above as indi e .
Date Issued //3-;9 2 Registrar of Vital Statistics
(signa e)
District Number S` Placed _ hl —
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
_ t
Date of Disposition L-1 Place of Disposition
r/ � 4J Gj�.� Zel'c rCl
(address)
mi
10, (section) lot number (grave number)
Name of Sexton or Person in Charge o Premises 7
(please print)
signature 9J Title
DOH-1555 (10/89) p. 1 of 2 VS-61