Parrott, Jane NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First M dle Lasj,7 Sex
Date of Death Age If Veteran of U.S. Armed Forces,
War or Dates
PI ce of Death `/ Hospital, Institution or
City, own or Village �lLs Street Address
anner of Death ERIN
atural Cause Accident Homicide Suicide Undetermined El Pending
Circumstances Investigation
Medical Certifier Name p ` Title
wir
Address /v/
Death Certificate Filed District Number Register Number
>> City, Town or Village
Date Cemetery or Cre story
❑Burial
Address
Cremation LP,vs 1-2 &0
Date Place Removed
ZRemoval and/or Held
••• and/or Address
Hold
0 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
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.
Date Issued /S Registrar of Vital Statistics
(signature) / ,/
oo
District Number Sc2�� Place /�y,,ol/S x)/ �� �
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
z Date of Disposition —I Place of Disposition/ //�•�
(address)
i�
to
>� (section) (lot p.umber) (grave number)
0 Name of Sexton or Perso Charge of Pr mises
g (please print)
Signature Al - � Title C �7
DOH-1555 (10/89) p. 1 of 2 VS-61