Moore, Jane NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Date of Death —7
j Age If Veteran of U.S. Armed Forces,
War or Dates
Place of Death Hospital, Institution or
City, Town or Village SSA,/� Street Address r�j
Manner of Death 2Natural Cause rAccident 0 Homicide Suicide Undet rmined Pending
Circumstances Investigation
Medical Certifier Name Title
Address S�
Death Certificate Filed istrict Number Register Number
City, Town or Village
Date Cemet or Crematory
❑Burial �� � �du �'e �I'-�/'l�A�r�!
Address
[Cremation ✓fin
gDate Place Removed
0 ❑Removal and/or Held
••- and/or Address
Hold
Fh
Q Date Point of
Transportation Shipment
tM 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 as indicated.
's Date Issued Registrar of Vital Statistics
(signature)
District Number Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
LU
Date of Disposition �Place of Disposition
(address)
iIJ
t/J
X (section) lot number) (grave number)
GName of Se nor Per on in Charge of Premises �j�/�� ���
z (please print)
Signature Title l��'L ,jam%Tr
DOH-1555 (10/89) p. 1 of 2 VS-61