Maynard, Bernard NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Biostatistics -Vital Records Section
Name Fir .
... M'. .- 1...:,i :) Sex
:W....Like...Of bee .:: Ace if Veteran ...rm-e- . drces, '1.4 ......... ...- • 417T-1'
War or Dates ..
Place of Death Hospital, Institutio o
.City,Town or Village _,..--'
:: Street Address
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... ................. . ..
1:1 Caus f Death . c-
V , ertifier e . tle ...... -•.......- ......................... .............
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•:.:.:::::::: Death i icate iled District u-'''''''.... .......... j '' Register Number
City,Town or Village /
g
Dfrtii
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M• ['Cremation f. ss - ..
''''':".'• .. . ....... . .. .. ...o,!r•-.. - „.,(..LizZe..
Z Date P Removed
„. .......
.
(;)i 0 Removal i ' nd/or Held
-; and/or Hold t
IA<
:•12:: bafe li. Point of
Cl) EjTransportation by
Shipment
i•::,•,:, ii Destination
,m. .... ..... . -.: ... ......
•
Date Cemetery Address
Disinterment
Date f. Cemetery Address
Reinterment
- •
• •
. • _
,,
Permit Issued to
4 \--•
/ Registration Number
..
Name of Funeral ' r) ../....e..,,,,,e<,A a ..4A„...,y4.. ........ ...................e223.3...........................
W Address
.•-d 7 rd ip.,- ,
,1_,e1„9. . -....7......044'.W/..... ........................____ ,
Name of Fu Firm akin Ir"S% 06n or -Who
ii.zi Remains are Shipped, If Other than Above
4.tV
....,.............
Permission is hereby granted to dispose of the hum remains cribed abo -"as indicated.
Date Issued y-..5-- J.*, Registrar of Vital Statistics •
(signature) 042
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.......
...... . .
District Number L__. gd Place • -/.7#;o1
I certify that the remains of the decedent identified above were disposed of in, rdance with this permit on:
•-•tE
•Z' Date of Disposition i- to,- ?? Place of Disposition p
:Ai e V i •- ees,"..rrtr t) (:Sli Q er ox 4.0 i..)
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(address)
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to. (sr) 4S...— (lot number) (grave number)
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rj. Name of S r Person in Charge of Premises cz,d
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•:-:]] Signature Title
DOH-1555(9/86)p 1 of 2(formerly VS-61)