Godfrey, Charles NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Date of Deatr� Age If Veteran of U.S. Armed Forces,
g War or Dates L&) 77-
Place of Death Hospital, Institution or
City, Town or Village 6 Lz Street Address � r k-
Manner of Deathf- Natural Cause Accident ❑Homicide Suicide Undetermined El Pending
Circumstances Investigation
Medical Certifier Name Title
r' �' L 2 Q '� w1�n M1
Address
Death Certificate Filed District Number Register Numb i
City, Town or Village ��^^�1�Sn S
Date Cemetery Qr Crematory
❑Burial
Address
Cremation J�P��sdUr�Y/ /yI /'d y
Date Place Removed
ZRemoval and/or Held
••• and/or Address
Hold
Q Date Point of
0.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
Address
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 remains described above a InMcd.
Date Issued f d a Q� Registrar of Vital Statistics �t
(signature)
District Number 56 � 1 Place ���� ���� STkf
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition Place of Disposition /?/ /Y� l�Z�'C e�i�/l� i
T(address)
iu
N
t>E (section) (lot number) (grave number)
O Name of Sexton or Person in Charge of Premises dzf ',q
g (please print)
��—Signature Title
DOH-1555 (10/89) p. 1 of 2 VS-61