Learned, Eileen NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name �,it t Middle Last Sex
G 4e '^Ive el
Date of Death Age if Veteran of U.S. Armed Forces,
02 War or Dates lt/b
Place of De th Hospital, Institution or
City, Town or Village Street Address arc!
Manner of Death ®Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier N/rye„ � .� Title
�J 4rc
Address
aJ.
>< Death Certificate Filed District Number Register Number
City, Town or Village
Date S_ cls Cemetery or Crematory
❑Burial ,iv s
Addre / (�
21Cremation fj�,�� 17�,✓
FDate Place Removed
Removal and/or Held
p and/or Address
Hofd
Date Point of
Q Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Regis ation Number
Name of Funeral Home Q ldd
Aggress
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
N.
Address
Permission is hereby g anted to dispose of the human remains de�Sri\be bo as indicate
Date Issued ! Registrar of Vital Statistics
( ignatur
�y
District Number 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 f4' /s / �e� G
(address)
LU
(section) (lot number (grave number)
GName of Sexton r Person Charge of Premises .�L7J1,
g _. (please print) �—
Signature } Title
DOH-1555 (10/89) p. 1 of 2 VS-61