Burgess, Betty NEW YORK STATE DEPARTMENT OF HEALTH 75,5"
Vital Records Section Burial - Transit Permit
Name First!!,,.,e,e7 Middle Last
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Date of Death Ag If Veteran of U.S. Armed or"F ces,
"3/A-7/a6/7 7 War or Dates
Place of Death Hospital, Institution or
w City, Town or Villag%�GI�tiO Street Address (,l�ft �-/}�
W Manner of Death IA latural Cause ❑Acc ident ❑Homicide El Suicide ❑undetermined ❑Pending
Circumstances Investigation
w Medical Certifier Name Title
tt ddress �n
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Death Certificate Filed Di rict Number Register umber
City, Town or Village........ aJtA c_ y$b' 1co o
❑Burial Date UU Ce tery or Crematory
❑Entombment
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DI
Address � - ii`'v ` ;1 gd 4
'Cremation
Date Place Removed
Z n Removal and/or Held
0 and/or
Address
{0 Hold
0 Date Point of
ft❑Transportation Shipment
0 by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home d t-1'4
mi Address
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gi Name of Funeral Firm Making Disposition or to Whom
.14 Remains are Shipped, If Other than Above
Address
CC
ll
fl` Permission is h eby gr nted to dispose of the human remains ri abo dicate
Date Issued - Registrar of Vital Statistics �'
(signature)
il District Number I� ( Place
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
Ili Date of Disposition )3o f(-t Place of Disposition -R txv✓ oat.._
2 ! (address)
W
tO
(section) (lot num ) (grave number)
0
C: Name of Sexton or Person in Charge Premises Ar+ /-, M4(ft
( ease print)
w 1Z i
::: Signature l-�t 6 Title .
(over)
DOH-1555 (02/2004)