Still, Gladys NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Biostatistics -Vital Records Section
gii Name First Middle Last Sex
iii:n. C./..4 i.Date of Death y /77..................:............................................Sy..:�,.1:::::: > ;.::::::::::.
Age If Veteran of U.S.Armed Forces,
War or Dates
lace of Death / / Hospital, Institution or
111 City,Town or Village if ..r...a..... Street Address 0.�..e3:... .. ..'a.. ........ ..
<D Cause of Death ti
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7 ,„
iw Medical Certifier Names Title
re
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.::Mii Address .............................�.......................................................................................
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Death Certificate Filed District Number 'Register Number
City,Town or Village I C‘ 7 gi 7
Date Cemetery or Crematory
2 BurialA/Vc p " D. (1
❑Cremation Address /✓ /4,a...e.Jr2 1-N s Az.-y
Z Date Place Removed
O ❑ Removal and/or Held
and/or Hold :::::::::::.:::::::::::::::::::::::::::::::::::::..::::::::::.::::::::::::::::::::::;>::::::::::::::::::::.::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::.::::::::::::::::::::::::::.::::::::::._::::::::::::::::::
. : Address
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la. Date Point of
•N: ❑Transportation by Common Carrier Shipment.............................................................................................................................
......... ...... .
Destination
❑ Disinterment Date Cemetery Address
...............................
El Reinterment Date Cemetery Address
SO Permit Issued to / `� Registration Number
Hiii Name of Funeral Firmwe
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iiiiiiiiii Address U /
G
Name of Funeral Firm Making Disposition or to Whom
mi Remains are Shipped, If Other than Above
Address
tint:
ah......_._......_.......
Permission is hereby granted to dispose of the hum r main described ab as indicated.
Date Issued /b'��- / Registrar of Vital Statistics
f (signature)
District Number Place
iini
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
F"
w Date of Disposition !I-Q2J -yr Place of Disposition J 4/9 V1 i) Ce=itix-te•-ie1) 9 te L tis u R y) Aiy
,2 (address) ,� !
U /tee li111. S pnJ 14
o (secQ) (lot number) (grave number)
p• Name of Sex Person in Charge of Premises •'. GA 1...? r� • ry't .1--, t� .C�y.
Z (please print) ` r`
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w Signature ),. -. YL(1-1-3 0"41- Title ) 11 p7-c
DOH-1555(9/86)p 1 of 2(formerly VS-61)