Spain, Jeannette 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,
�S e T War or Dates
Place of Death Hospital, Institution or
City, Town-er-V*age Street Address e
Manner of Death Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Address
Death Certificate File (' District Number Register Number
City, To e
Date Ce tery or Crematory
❑Burial
Address Cremation
Date fit/ y
Date ton Place Removed
8❑Removal and/or Held
-• and/or Address
Hold
O Date Point of
N Q Transportation Shipment
y by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home _ 7 o
Address ,J
-
Name of Funeral Firm Making Dispositiofi or to Whom
Remains are Shipped, If Other than Above
Address
Permission is here y gr ted to dispose of the human rem 'ns es q�/e�d�ab�ov s ' dicated.
Date Issued l yS Registrar of Vital Statistics
(sign re)
✓
District Number S 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
12 l (address)
Uj
0 (section a ( A104)
(grave number)
Name of Sexton or Perso in Charge of remises /L��
(please print) r
Signature Title
DOH-1555 (10/89) p. 1 of 2 VS-61