Justia, Geraldine NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Biostatistics -Vital Records Section
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First Middy Last Sex
iM o ea Age If Veteran of ed orces
War or Date
Place of Death Hospital, Institution or
IJ City Town or Village - Street Address
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fiipal C.,„frArtifi Name Title
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D at erti icate Filed Dis riot umber Register
City,Town or Village 4(..�.4 S"� l 'i
f' tery or Crematory -
❑Burial 2
ZI-erUmation Adar '
z Date Place R
O 0 Removal c emoved
F- and/or Hold ... : .:.. .....::::
/ and/or Held
Address
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n. Date Point of . ..:::.:..... .. . ....: ....:....... ...:.
0 ❑Transportation by Shipment
p Common Carrier ......_.est...:::. ... ... ...:.....: .....::
Dination
❑ Disinterment Date Cemetery Address
❑ Reinterment
Date Cemetery Address .:..:.........::...........:.... .......,.:.......
i Permit Issued to 2 Registration Number
Name of Funeral Firm
Address
. of ne a irm or to Whom
3 i ,Xing Di position ,'
;j Remains are Shipped, If Other than Above
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Address
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Permission is hereby granted to dispose of the dead an r_, `al s desc/ •ed above as indicated..
Date Issued S— Registrar of Vital Statistics 4 ..cf, -- 40-c'`--/ /
Iiiiii (signature)
District Number � e
3�j0/ Place/`�J
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I certify that the remains of the decedent identified above were dispose in accordance with this permit on:
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Z. Date of Disposition ir/2'°'/� Place of Disposition )i 0 e C i e ipi y.- 1--`4)c i J—t
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2 (address)
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ice:: (section) (lot number) (grave number)
p' Name of Secton or Person in Charge of Premises --J (L.. h ,, J �v 1 ✓- •
W . (please print)
Signature l~ Q /2 4 L.»-- Title ( e; - et C/ , ,•s 4--
DOH -1555 (9/86)p 1 of 2(formerly VS-61)