Schermerhorn, Alan NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
Date of Death Age If Veteran of U.S. Armed Forces
War o..Dates
Place o eat Hospital Institution or
City own r Village (,J Street Address
.............. .,..
... ..... . ............
:01
Manner of Death ❑ Natural Cause ❑ Accident ❑Homicide ER Suicide Undetermined Pending
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Circumstances Investigation
lV Medical Certifier Name Title
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Address
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Death Certificate Filed District Number Register Number
City, ow Village
Date Cemetery or Crematory
❑Burial
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®Cremation Address
Z Date Place Removed
O'', [] Removal and/or Held
F-' and/or Hold ..:. ....... ......... ::::. ... _.:::::::
Address
IL Date Point of
N ❑Transportation by: Shipment
p Common Carrier .::::::::...
Destination
...................... .....................:.......... .: ... .......... ....... ............
❑ Disinterment Date Cemetery Address
... ........
❑ Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Firm ..VS/►'1 ZAX--
::. :.. Fviv� Tz.. .... ... r . .
Address
7........
4'. Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, H Other than Above
..-..... .:....... ..................................................-
Address
s >
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued egistrar of Vital Statistics C
(signature)
District Number cad 0 s Place �JLI -9 �
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition "//'"� Place of Disposition / A4F /'�C 14:716. 0
2 (address)
w'
N` (section) (lot number) (grave number)
cc
p' Name of Sexton r Person in Charge of Premise
Z lease print) — -
W' Signature Title O !
DOH-1555 (10/89) p. 1 of 2 VS-61