Fleming, Grant NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Biostatistics -Vital Records Section
Name Fir Middle Last ....Sex
Date of Deat Age If Veteran of U.S.Armed Forces
........
War or Dates
'•Z Place o .each Hospital, Institution or
:. Cit •r Villa e
y. . g Street Address ,¢.._ - �-
>. Cause of Death
Ail Medical Certi ier N e )5!
Address
Death Certificate Filed ...........................................:.
/ 'strict Number Re 'is#er umber
iiMii City,Town or Village �f" `6—�",r
Date .,- -ry or Cre tort'
ElBurial l '
Cremation AOresg
--
.....;.::.............................
Viz' Date Place Remov
Q ❑ Removal i and/or Held
't- and/or Hold Address • :::;:.:::::::::::::::.:::.:..:: :::::::::.::.::::--::::::::: :::::::: ::::::::::::::::::::::::..:::::::::::::::: :::::::::::::::::::::::::.::::::::::::
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cl)
;G Date Point of...........................................................................................................................::..
w ❑Transportation by Shipment
Common Carrier
Destination
Date Cemetery Address
El Disinterment
El Reinterment
Date Cemetery.Address
€€ Permit Issued to Registration Numb r
Name of Funeral Fi4 C
. :;:.:::::::::::::::....:::,..................................
:.... Address::
r7
:>:<:;
Name of Funeral �
... ..................................................................................................................................................................
1, Firm Making Disposition to Whom
Remains are Shipped, If Other than Above
.. ......................................................................................
;ire Address
AU
RE Permission Is her by granted to dispose of the dead human remains describe ,a ye as indicated.
Date Issued // 3ri Registrar of Vital Statistics
(signature
�J C
iiiiiiiiii Distri n ct Number.6 / Ss"( Place . .. /�0 7
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
•w Date of Disposition Q `/er7 Place of Disposition j".s1..� �,,.o'car, t=---,ti /4 c 69c - �`-,�-4,.h.c27 2 (address)
ur
(section)4 (lot number) (grave number)
:Oil
a Name of Secton or P son in Charge f PremisesALI
'l'°� /7 5 1
Z (please print)
Signature Title r� j
DOH -1555 (9/86)p 1 of 2(formerly VS-61)