Davis, Harry NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
s' Date of Death Age If Veteran of Arm ad Forces,
/ �, '7a War or Dates
Place of Death Hospital, Institution or
City, Town Villa Street Address
Manner of Death Natural Cause Accident Homicide Suicide Undetermined Pimding
Circumstances Investigation
Medical Certifier Name Title
n
Addres
rR e. /
Death Certifica � _ District Number Register Number
City, Town or illage r— nui
ate Cemetery or Crematory
❑Burial /
Address
linIIJ Cremation / &
Date Place Removed
0❑Removal and/or Held
••. and/or Address
Hold
Q Date Point of
Q Transportation Shipment
fl by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home /� �; Q
Address
5 /
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Aa
Permission is hepby granted to dispose of the human rem 'ns described above as indicated.
Date Issued Registrar of Vital Statistics
��!:�/��
(signature) lI
District Number Place_ Y iA/���7 D'T (�l^l9/l�L9i //
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition s t 3- (� Place of Disposition �j f'lr��j�t�/ C'n f'A1 R 4
(address)
iU
t/J
> (sec ion) n u lot numb (grave number)
0 Name of Sexton or Person in Charge of Premises
g (please print) _
Signature Title �/1. �' ' r
DOH-1555 (10/89) p. 1 of 2 VS-61