Nelson, Martin NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Biostatistics -Vital Records Section
Name FirMi die
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iiiiiiiii Date of Dea z Age If Veteran of U. .Armed orces,
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--, War or Dates
Place of Death Hospital,Z ospita Institution or
<. City,Town or Village � '
};i,17 9 Street Address
4 Cau of Death, _ v
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mi Uthifiail7 ' T District Rumber / Register Number
City,Town orvillage ef_j>4' l 1/ 3
e ,i, Cemetery or Crematory
❑Burial •
mation Addre s -_ , �r7—
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Place Removed
C1 ❑ Removal and/or Held
and
/or Holdۥ :
�' Address
Ni
o. Date Point of
N: ❑Transportation by';
:p Common Carrier Shipment
:::.....................
..................................................................................................................................................
Destination
.........................................:::::Date::::::..................................................... ..............................................................................................................
❑ Disinterment : Cemetery Address
....::...........................:.............:.:.........:.::........:::.:...........::...........:..........::......:.
❑ Reinterment Date Cemetery Address
•
Permit Issu
ed to Registration Number
Name of Funeral Firmr
Address //)..0..-emcY ::::: ��- . .... -::.::.:. ,mot/...::..::: :::: ::::.::::::::::::....,:- ;;::. 3,54/
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„:, Name o uneral Firm its on or to om
"" Remains are Shipped, If Other than Above
Atji
�� Address
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...........................................................:::.:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::.
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Permission is hereby granted to dispose of the dead n re ins descr ed above as indicated.
Date Issued ,.„1-- - 67 Registrar of Vital Statistics ..4.s4"-
signature)
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District Number 6d j Plac ,f� Fp / , �ry/
I certify that the remains of the decedent identified above were disposed n accordance with this permit on:
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W Date of Disposition 2 /31 1"7 Place of Disposition ��/ �°t e C�'"e ,? /9 fc r' /v--I
:.2: (address)
(address)
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o (section)_ (lot number) (grave number)
p Name of Secton or Person in Charge of Premises J �„ h ki ;J . IZ o s J
w 1 (please print)
Signature �- '�� P: Title Pcr`S7C,;1 , r, C L, rr C
DOH-1555(9/86)p 1 of 2(formerly VS-61)