Gordon, Shirley NEW YORKSTATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
>� Name First Middle Last
Date of Death Age If Veteran of U.S. Armed Forces,
ro War or Dates
Place of Death Hospital, Institution or
City, Tome Street Address
Manner of Death®Natural Cause ccident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name — Title
Death Certificate Filed District Number Register NVmber
City, Town or Village
Date _ Ce tery or Cr atory
❑Burial
Address. �
Cremation
Date Place Remove
8❑Removal and/or Held
and/or Address
Hold
Date Point of
Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
r Permit Issued to Registration Number
Name of Funeral Home
Addres
Name of Funeral Firm Making isposi ion or to Who
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human re ms a ibed b e as dicated.
Date Issued ' 3 �� Registrar of Vital Statistics ., f
(sign 'e)
District Number 25/ Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition "" Place of Disposition
(address)
(section) (lot number / (grave number)
Name of Sexto or Person n Charge of Premises .�IJi.�it� 4�'
(please print)
Signature uJ TitleS�rt
DOH-1555 (10/89) p. 1 of 2 VS-61