Wilbur, Maynard NEW YORK STATE DEPARTMENT OF HEALTH '- - 4 QL
Vital Records Section Burial - Transit Permit
Name/'// eX2fid Middle JL,ast� Sep
Date of Ni `�Deatl/ Age?.3 If Veteran of U.S. Armed Force o
i r 2e9e) 6 �3 War or Dates
Plac- • !-- h / Hospital, Institution o ,/ � �f�����
vs. C. y, own : Village �1/2_(Pok-a?/ed Street Address /2 l/y7. (� f
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-r of DeathjNatural Cause D Accident 0 Homicide 0 Suicide Undetermined 0 Pending
4W Circumstances Investigation
Medical Certifier me Title
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`:<` Deat rficate Filed ,�-- /�� District .N�u�� Register Number
Citf'?o�r Village j`'—�l�7-S-c o��
Date // C etery or Crema
❑Burial7...aci_2)6
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WWAddress
Cremation OE 0 P gai t=7C'ifr7Sat.- l2c�f
Date Place Removed
0❑Removal and/or Held
..- and/or Address
15 Hold
En
Q Date Point of
5 0 Transportation Shipment
E by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
:« Permit Issued to `—`- 'r ' Registrattiipn Number
Name of Funeral Home �� �-- l` ,t vwx_ i( C 4 tug �`C-` v e 7 3
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�� Making Disposition or to Whom
:;: Name of Funeral Firm a g p
Remains are Shipped, If Other than Above
Address
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Permission is ere y granted to dispose of the human re ins described abov as indicated.
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Date Issued,TS 6 Registrar of Vital Statistics f ,
_ (sin e)
J Place itflAir) '�ur iiN Distract Number�24
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I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition S-I )L Place of Disposition 1p,y,t 4 A.''N' 6,,^`}of Ate'^
2 (address)
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Ce (section) (lot numllz) (grave number)
GName of Sexton or Person in Charge of Premises C r%{ S,,t.rntu
Z '-I (please print)
W Signature C�- Title Cren.-<
DOH-1555 (10/89) p. 1 of 2 VS-61