Arnold, Elma NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
J, b
Date of Death Age If Veteran of U.S. Armed Forces,
War or Dates/vp
Place ath Hospital, Institution or
, w Cit To _ r Village �Z,d� y j�Ult1�U Street Address w L Il p //��
C. Manner of Death LRNatural Cause ❑Accident ❑Homicide ❑Suicide Undet rmined ❑Pending
Circumstances Investigation
Medical Certifier -Name Title
Addres
7"ad e"14�J4 X/
Death icate Filed istrict umber Register Number
Cit Tom r Village
Date �- Cj etery or Cremat ry
❑Burial
Address
Cremation
Date Place Removed
Z❑Removal and/or Held
•• and/or Address
0
Hold
Q Date Point of
4.❑Transportation Shipment
by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home
Address
/Z k7.5-
Name of Funeral Firm Making Disposi ion r to Whom
Remains are Shipped, If Other than Above
Address
Permission is he by ranted to dispose of the human remains described above\as i dicated.
Date Issued /0 J_ Registrar of Vital Statistics
(signature)
District Number_ Place P
I certify that the remains of the decedent identified above were disposed of in acjco�rdance with this permit on:
LU Date of Disposition S Place of Disposition a" f/V,k:-
(address)
11J
C (section) (lot num er rave number)
GName of Sexton or Person in Charge of Pr mises � �i_�,�
z (please print) �-
Signature Title
DOH-1555 (10/89) p. 1 of 2 VS-61