Rouse, Ethel NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name it t Middle ^ Last ¢o�_
,94
Date of Death Age If Veteran of U.S. Armed Forces,
g� War or Dates
Place of Deatli Hospital, Institution or
City, Town or Village Street Address
Manner of Death NaturaK use ❑Ac nt ❑Homicide ❑Suicide Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name o 1 ( nTitle
Address
SV���,4 ,2e� J
Death Certificate Filed District tuber Register um r
City, Town or Village S 6
Date ` Ce tery or Cr matory
❑Burial
Address
RCremation
Date Place Removed
0 ❑Removal and/or Held
-- and/or Address
Hold
Q Date Point of
N ❑Transportation Shipment
by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home i
Address
Name of Funeral Firm Making Disliosition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remain es ri I above indi ated.
Date Issued Registrar of Vital Statistics
(s nature)
District NumberOM
s Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
f-
g Date of Disposition S Place of Disposition P j Al e U/ e w C f e-In& To ,NY
W.
(address)
UJI
> (section) (lot number) (grave number)
0 Name of Sexton or Person in Charge of Premises , l C,�/� / 1G�eim
Z
z (please print)
Signature Title
DOH-1555 (10/89) p. 1 of 2 VS-61