Cohen, Celia NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Biostatistics -Vital Records Section
Name First 1,, Middle Last ];..
:i ii Date of Death Age If Veteran of U. .Armed Forces,
44. --- ill 7 <I7 War or Dates
•-- Place of Death'= Hospital, Institution - ,---
::.i4 City,Town or Villag3„4e/ Street Add
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itu lc Cert9r . . .. -Title
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11(. s.9*,; e t-a-.4 e J1,, _,..,. e,i4e-e:, — ,,/, -,-/C /
e th C ific te Filed / Distric Number Register Number
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ma City,Town or Village "5----ti (--V17
•:!:!,,' , ___......--- Date :3-- 3--;t7 Ce ip,t e' or Crematcy,...--
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Z - ate
0, 0 Removal 7 /or Held
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1,, and/or Hold ii-Address
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Date Point of
(0: 0 Transportation by
Shipment
el• Common Carrier
Destination • •
:. Date Cemetery Address
0 Disinterment
Date Cemetery Address
-• El Reinterment
Ng Permit Issued to ,.--.. i - Registration Number
illi .Name of Fu Firm Slig",4,0A.,
ma Address .1 e-.
, .
Remains are Shipped, If Other than Above
Address .
AIX
Permission Is hereby granted to dispose of the dead h rem in scri ed above as Indicated.
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Date Issued 5 --,5---,7 Registrar of Vital Statistics
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......
.......
District Number j----4,, ( Plact1.4.41-c3a...e.ep. //... ,./.77 /
I certify that the remains of the decedent identified above were disposo of in accordance with this permit on:
Date of Disposition Place of Disposition
Au:
(address)
41
:v)•
itt (section) (lot number) (grave number)
..0 Name of Secton or Person in Charge of Premises
•Z (please print)
1.1J
• • Signature Title
DOH-1555(9/86)p 1 of 2(formerly VS-61)