Lamphere, Frank NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Biostatistics -Vital Records Section
mi Name First
Mkldle (2e Last :. Sex
Date of P.M beaili71P/17• .i:: Age .
, i.:• ff Veteran of U.S.Arr71k.F.Iirces,7137 "2 War or Dates
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= Hospital, Institution or
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iii4 City,Town or Village j/-4...,)„.4 fivi.„...,/jty Street AddressCause of Death r-a.12.4...)
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la Medical Certifier Narriii Title
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Address
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**i*: Death Certificate Filed DiiiriCiA.jm er Register Number
!!iM City,Town or Village s't7. ''.;,.‘ .--7/
ii Date ---/ .
1 Cemetery o rematory
Burial 3/. - 3/P 7 ,
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3 C i Address
remation
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:::• Date
z: ii Place Removl
(:) 0 Removal and/or Held
,:•1..., and/or Hold
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0.• :::: Date Point Of
N. Ej Transportation by
.:,-., .Common Carrier , Shipment
f.: Destination
Date :,
Cemetery Address
El Disinterment
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Date Cemetery Address
iip:i El Reinterment
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iN Permit Issued to i Registration Number
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.M: Name of Funeral Firm " ..."--- <PA't
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!in Address ?
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ig• Name of Funeral Firm Making Disposition or o Whom
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Remains are Shipped, If Other than Above
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ltr. Address
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Permission Is h reby granted to dispose of the human remain escribed above as Indicated.
Date Issued ' Registrar of Vital Statistics .g, rf,
' ignature)
District Number '_ / Place 74--e---) /1Y, / )7ib/
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 5-?3-8i7 Place of Disposition P
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"cc (s.2513) (lot number) (grave number)
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::a Name of Sexto son in Charge Premises
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,,, :• Signature , ,... <„,i2,,,, 4 ,__...,„ Title ,
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DOH- 1555(9/86)p 1 of 2(formerly VS-61)