Forgette, Mildred NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Biostatistics -Vital Records Section
iNiii Name -- Middle Last Sex
< > Date of e h G Age if Veteran of.Or orces,
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i.z Place o Death i Hospital, Institutio or
Iii City,Town or Village Street Address
<f'�..Cau of Death
ae ' de ter Nfime `� - Title
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Ad ress
Deat ertificate Filed District Num Register Number
Ni City,Town or Village A-'9. •J aQ,4- ,...-6e'/ ‘ /
11 Datil / Crate or Crematory
❑Burial
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Address
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:Z; Date Place roved
o ❑ Removal r Hid
.' and/or Hold `
Address
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a Date Point of
Cl) El Transportation by Shipment
ArlCommon Carrier
.. ........................
': Destination
❑ Disinterment Date Cemetery Address
.......................................... ........................................................ ::::::Address:::::...................................................................................................
❑ Reinterment •
Date Cemetery
Permit Issued to i - Registration Numbe
Name of Funeral Firm i
ss
n
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''"' �� ��� ��a of Fun I irm Makin is sitio��oror to Whom
iz::i Remains are Shipped, If Other than Above
:: Address
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:.::::.:....:...................................................................................................................................
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Permission Is hereby granted to dispose of the human r ins scribed a ve as indicated.
iiiiiiiiiiiii Date Issued /c)-- /0 42, Registrar of Vital Statistics
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District Number 0 to0 Place rv/2 d .r°i _ ��t /
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I certify that the remains of the decedent identified above were disposed of in accor nce with this permit on:
wDate of Disposition ///t7 Place of Disposition Ara z LA-"-7nAl e v.',-:*=v I r� , Qu-4t-,-.,�..a.-4.1
M] (address)
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(section) (lot number) (grave number)
p Name of Sexton o. erson in Charge of Premises
Z /l (please print)
w Signature iet. _- Title it c 1^
DOH-1555(9/86)p 1 of 2(formerly VS-61)