Burns, Richard NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Mid le Last
Date of De Age If Veteran of U.S. Armed Fo
War or Dates
Plac .o#^Be Hospital, Institution or /
City, Town Villag .; Street Address Y
Manner o Death Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
!�WMedical Certifier Name Till /
Address 6
<> Dea tificate Filed District Numbea j ,.-/ Register Number
City, Town r Villag ((�
Da Cem4jry pr re atory
El Burial
,,.�,,// Addree
2 remation
Date Ice Re oved
❑Removal and/or Held
Z
0 and/or Address
Hold
Q Date Point of
[�Transportation Shipment
fl by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Reg,is-t�ation Number
Name of Funeral Home
Address
Name of Fu eral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
A.
Permission is h reblranted to dispose of the hum n mains describe above as indicated.
>« Date Issued Registrar of Vital Statistics
{ ignature)
District Numbe Place
I certify that the remains of the decedent identified ab e were disposed of in accordance with this permit on:
e
Z Date of Disposition ^( Place of Disposition �} 3 t 1� L/1�1 1 Q i L)fl/(address)
iw
.0
cc (s tion)tr`2 �-�1` y .}�Aqt t I'
numb (grave number)
Name of Sexton or Person in Charge of Premises g►� �. V,r ��
z (please print t
Signature / Ti
t
le
DOH-1555 (10/89) p. 1 of 2 VS-61