Dare, Arthur NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Biostatistics -Vital Records Section
Name Fir Middle Last Sex
Ni>. Date of Death Age If Veteran of .S.Armed Forces,
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Place of Death;�..r Hospital, Institution o
iui City,Town or Village Street Address ./s. ve-r,
taus f Death
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Ail a Ica Certifier -,,,0 a Title
Addr ss
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ini D h Certificate F. District Number Register Number
iiiiiiiiii ity own or Village ice,( _ . ' ti5-4. / ,3 S7
Da ry remator
0 Burial /V 2'7
remation
Address ::. ... ....... ...................................... .......
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Z' Date i Place Rem d
0: ❑ Removal and/or Held
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and/or Hold :::
Address
E.O.: Date Point of
>fn> Transportation by Shipment
O, Common Car Ier
Destination
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❑ Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
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Permit Issued to Registration Number
Name of Funeral Fir toe. a 4.4 J 9J
Address /
2 ., ?aA-Ar/.). -• /a-e,-e. c...4i 41-(--e-'4. 4 ,1 '
3- Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
:. Address
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Permission is hereby granted to dispose of the dead hymen remains described bove as indicated.
Date Issued 7—/V I'7 Registrar of Vital Statistics c% V d /
ignature)
District Number L 57'i/ Place �i{Fa /
I certify that the remains of the decedent• entified above were disposed of in accordance with this permit on:
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Z Date of Disposition 7/`l/n Place of Disposition 7C 4-4-", r"-/ CP &--
2I (address)
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ICIC (section) (lot number) (grave number)
p' Name of Secton or erson in Charge of Premises 477n 420.1--
Z (please print) 1
W' Signature L.''�-�-� Title a r rIY
DOH-1555(9/86)p 1 of 2(formerly VS-61)