King, Edgar NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Mid le La t Sex
Q t'
Date of Death Age If Veteran of U.S. Armed For s,
q5 War or Dates
APlace of Deat Hospital, Institution
City, Town Vilar"�"i/' Street Address
Manner of Death Natural Cause Accident Homicide ❑Suicide Undetermined ending
Circumstances Investigation
M.
Medical Certifier Name kar-en kir
Title
Address
Death Certificate Filed District Number Register Number
City, Town or illa Q{� /���, ��a�s 9
Date Ce tery or Crema�y
❑Burial g qq5 pileV C."W f1'l t` o 1-
AddressX Cremation --5&Ar
FDate lace Removed
Z ❑Removal and/or Held
0 and/or Address
0
Hold
Q Date Point of
Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to -T- Registration Number
Name of Funeral Home V1.5 M r Fun 00� S
Address n
rl S he,r►�a, (.Sri Y l 8a
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above _
Address
Permission is hereby granted to dispose of the human rpm,ins described above indicated.
Date Issued 9J� Registrar of Vital Statistics
(s n re}
District Number o?J�" Place QYI 1�'
4
I certify that the remains of the decedent identified above
were disposed of in accordance with this permit on:
Date of Disposition lace of Disposition
(address)
U
N
>� (section) (lot number) (grave number)
CName of Sexton or Person in Charge of Premises
g (please print)
W Signature .
DOH-1555 (10/89) p. 1 of 2 VS-61