Smith, Quinton NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First `Q Midge L�/ �1 Sex/C TGL
Date of Death 7 7 Age If Veteran of U.S. Armed Forces,
•� War or Dates
''' P of Death /jam Hospital, Institution or
' ..� City, own or Village `l Street Address !/
anner of Death atural Cause-Q Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
4x1 S�rv2..D 1H l)
Address
Death Certificate Filed District Number Register Number
City, Town or Village �p�,c�,., �� �j�Q
Date Cemete or Crematory �}
❑Burial
n _I i es
HUUI CJS
remation
ZDate Place Removed
0 ❑Removal and/or Held
and/or Address
Hold
Date Point of
N Q Transportation Shipment
d by Common Destination
Carrier
[�Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to / � Registr oru tuber
Name of Funeral Home -re, —Af,1 �`!i/r� �dp�
Address n
r!' � ��• vC�id s hie OV� �a-d`Q
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
U.
Permission is hereby granted to dispose of the hurnan renk inns described above asGyyn .te .
Date Issued Registrar of Vital Statistics
(signature)
District Number AGO Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
` �
F Date of Disposition f Place of Disposition d Ai� yie/ /(J /rl�
(address)
W (section) (lot number) (grave number)
QName of Sext or Pers in Charge of Premises
g (please print),.; t
Signature Title t>/1 ' /
DOH-1555 (10/89) p. 1 of 2 VS-61