Fitzgerald, John NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Date of Death Age If Veteran of U.S. ArmedF ces,
"q,.) _ a C/��� jl War or Dates
Place of Death p Hospital, Institution or
City, T ' e Street Address
Manner of Death Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined Pending
Circumstances Investigation
Medical Certifier Name �itle /� n
/t G /'✓ p j e e Y
ddr
Death Certificate Filed t7 District Number Register Numbeen
City, Tewa..oLV age 0 r
Date _ Ce pUtry or F7matory
❑Burial
Address/`
Cremation
Date Place Removed
Z❑Removal and/or Held
.. and/or Address
Hold
0 Date Point of
N❑Transportation Shipment
by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to - j Registration Number
Name of Funeral Home X
Address (1
Name of Funeral Firm Making Disposition r to Whom
Remains are Shipped, If Other than Above
Address
Permission is h eby ranted to dispose of the human remain ri above apollh7tfated.
<` Date Issued 01 95 Registrar of Vital Statistics
(signatu
District Number
Place -
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
DW. ate of Disposition/7 Place of Disposition / ,/�ir/.F !//k—V eh7,� 7eyF �
(address)
f�
(section) � (lot number �(grave number)
GName of Sexton r Person n Charge of emises
g (please pant)
Title
Signature
/U
DOH-1555 (10/89) p. 1 of 2 VS-61