Simmons, Timothy NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First �-- Middle Last Sex
Date of Death / Age If Veteran of U.S. Armed Forces,
�9 g. War or Dates
Place o Death Hospital, Institution or
� �
City, �� Street Address a
Manner of Death Natural Cause Accident Homicide Suicide ndetermined El Pending
Circumstances Investigation
Medical Certif"r ---flame Title
Address
Death Certificate Filed ' , Distric Number 4register Number
City, �� 7 57
Date Cemet or Crem ry
❑Burial e / 199S � �
®Cremation A ss
FDate �X•� lace Rem ed
SF-1
Removal and/or Heldv
-• and/or Address
Hold
Q Date Point of
Q Transportation Shipment
fl by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Q /O,f
Address ��� �na.�.•-� � � , /�o�
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 remai s described above as indicated.
Date Issued /g9R'egistrar of Vital Statistics C.
(signature)
District Number Place
I certify that the remains of the decedent identified above were disposed of in acc rdance v40 this permit on:
z Date of Disposition AL�3 Place of Disposition /1�1/160E-
(address)
N
(section) (lot numbeer), J (grave number)
GName of Sexton or Person in Charge o Premises ��, �
(please print)
Signature Titleelf"
DOH-1555 (10/89) p. 1 of 2 VS-61