Myers, Gertrude NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Biostatistics -Vital Records Section
F Name First -- Middle Last •., Sex
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Date of Death. Age r.., i: If Veteran of U.S.Armed Forces,
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Aiii! j Lt. i 4 i ct ( --7 --( / , War Veteran of
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Place of Death
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44 City,To -or Village /2 A./6 pi „.9‘.. , ..-i'4 Street Address ----Y4 P Aie, 41 to
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A e A v-T- Foll Cause of Death i)
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la Medical deitiiier Name Title
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Death Certificate Filed _ District 7 4egliieTi ibei
City,Towfrr-Vitt /1 " (yr -- / s0 / X
Date - Ceme . or Crematory-, .
:.. OBurial :.1- i .2_0 ( ?'-:: l'" C ft erv,A (0'- ' u
rij Cremation Address
CI E-r )-.s ' A (! ,C / ) --Lt - •• ....... ....... .........................................................
2 Date Place Removed
0 0 Removal --.:,. and/or Held
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1--. and/or Hold:::."Address .......
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. - - ---- - - - .--------- -
Ct. , Date Point
0 Transportation by f Shipment
:a Common Carrier - - --- ......... .......... ...........................................................................................................................................................................
Destination
• . ..... ..............................................................„........................................„.....
Date ::
:: Cemetery Address
:• 0 Disinterment
. . _
Date i Cemetery Address Reinterment
: .
Permit Issued to .,- i Registration Number
VA Name of Funeral Firm - . O -2 2. 7 7
Address
aft...........Lie__- 2 et.......c....0_141...7it )4...II__ ,..,7i• A.) i (), ty‘ k....
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g.i Name of Funeral Firm Making bispositiOnsoit1Whon.............................. u.............. 7..... -......7.................-......................... .....................
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Remains are Shipped, If Other than Above
Address
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Permission is/he eby granted to dispose of the dead hwna. r ains des4rLbed abofie as indicated.
Date Issued 2 2 0 f 7 Registrar of Vital Statistics
(si . fe>)
61 '
District Number "47'S 6) 7 Place ,196--4-- -,C W
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
1- ,-.., _ n n ,
FL, Date of Disposition 1:/2". 4r2 , Place of Disposition 6g"7-i• Ca.---g-ril A-rd•-•(-4-;"- -A'''' i Al 1 4 a a a'Us 4 6 4444"
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It ( eotion) (lot number) (grave number)
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Name of Secton Person in Charge of Premises 4-iv-IV .1..r-f
:::Z• Signature (please print)
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Title
DOH-1555 (9/86)p 1 of 2(formerly VS-61)