Phillips, David NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last S
�� s
Da f DeatV Age If Veteran of U.S. Arme Forces,'
1. -c_. oZ �. � War or Dates
Place of Death Hospital, Institution or
City, Tow ,n ^r VjtMno .{ Street Address
Manner of Death Natural Cause ccident Homicide Suicide 4Unetermined Pending
Circumstances Investigation
Medical Certifier Name Title
o r� X0
A ss
Death CertificateOPiled District Num er Register Num er
City, Tevv++-ef-�- '
Date Cer3r6Yry or Cr atory
❑Burial
Address
Cremation
Date Place Removed
8❑Removal and/or Held
�- and/or Address
Hold
Q Date Point of
Q Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home
<; Ad es
Name of Funeral Firm Making Disp sition or to Whom 100,
Remains are Shipped, If Other than Above
Address
Permission is he=2 ;
d to dispose of the human rem d ed a� as ' d.
Date Issued Registrar of Vital Statistics ce
(signat )
District Number �r0 Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition¢�" -9� Place of Disposition
W (address) '
W
(section) (lot number) (grave number)
G Name of Sexto or Person Charge of Premises ,4,J�l/�`(l� zz p�
;� (please print) _,.._.
Signature Title l� SSA /
DOH-1555 (10/89) p. 1 of 2 VS-61