Robinson, Gladys NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Od'�j
, IV �i—
Date of Death Age if Veteran of U.S.. Armed Forces, `
/ $` -7 War or Dates
'> Place of Death Hospital, Institution or
City, TQuw or !I1a" Street Address
Manner of Death Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Ova A
Address
6 7e
Death Certificate Fled I District Number Register Number
City, Towff PAIa e a�
Date or Crematory
:` ❑Burial a -j�
Address
ER-Cremation
Date Place Removed
0 Removal and/or Held
•- and/or Address
Hold
Date Point of
Q Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Re istration Number
Name of Funeral Home J `
// v
>' Address
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is here y gr ted to dispose of the human r ain d ribed ab=eaindicated.
'-> Date Issued / Registrar of Vital Statistics
(si nature)
<` District Number Place
I certify that the remains of the decedent identified above vZre disposed of in accordance with this permit on:
z f
Date of Disposition y��Place of Disposition / j,S)
(address)
g (section) � Slot numb r (grave number)
' Name of Sexto or Person Char e of Premises
(please print)
LU Signature Title
DOH-1555 (10/89) p. 1 of 2 VS-61