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NEW YORK STATE DEPARTMENT OF HEALTH f Itl
Vital Records Section Burial - Transit Permit
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Date of Death Age • If Veteran of U.S. Armed Forces.
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tz Manner of Death Natural Cause E Accident 0 Homicide 0 Suicide 0 Undetermined Pending
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^ Death Certific. - ' -d b �.ri I District Nufnber •1/l Register Number
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ii 1✓Cremati•on Address
Date ;J Place Removed
n Removal and/or Held
E and/Holdor Address
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Q ; Date Point of
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by Common Destination
Carrier
Disinterment Date Cemetery Address
' Reinterment Date - :. Cemetery Address
iiiii Permit Issued to Registration Number
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it Name of Funeral Firm Making Disposition or to Whom
gRemains are Shipped, If Other than Above
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iiqi Permission is hereby granted to dispose of the human remai s scribed awes indicated.
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Date Issued .3)g) 1 / Registrar of Vital Statistics /A2
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iiit District Number L15aL( Place c if ,1 (mil 9s cl(S
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on;
if E Date Disposition
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Er (section) f�lot number) (grave number)
0 Name of Sexton or Person in Charge of Pre ises tbr.;t f/ rn.i l*
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W Signature L'c r Title (A f-A04-
DOH-1555(10/89) p. 1 of 2 VS-61