Elmendorf, Elizabeth NEW YORK STATE DEPARTMENT OF HEALTH
Vital.Records Section Burial _ Transit Permit
Name sir/ Middle � Last
S �
Date of Death t Age If Veteran of U.S. Armed Forces,
j9 q� War or Dates
Place of Death Hospital, Institution or )
City, Timor Street Address 5 l�S OS I
:.: Manner of Death R<atural Cause Accident Homicide Suicide Undetermined EIP
ending
Circumstances Investigation
Medical Certifier Name Title
Address U` e,
Death Certificate Filed District Number
��GO/ egiste ��er
City, Tamer
Date Cor Crematory ^ l
❑Burial j- -9
Address
Cremation
Date Plac Removed
Z❑Removal and/or Held
-. and/or Address
Hold
Q Date Point of
Q Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registratio Number
Name of Funeral Home i o Y
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 i Lct ed.
Date Issued S Registrar of Vital Statistics
(signJat�uree)
District Number Jed 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
(address)
w
(section) (lot number) (grave number)
Name of SextorLor Person in Charge of Premises n-P J14
y (please print)
Signature Title �T`
DOH-1555 (10/89) p. 1 of 2 VS-61