Preal, Thomas NEW YORKS1AlhDEPAR1MENIOF-HEAL.1H Burial - Transit Permit
Bureau of Bioslatistics-Vital Records Section
Na Middle I�st
Date-ofDeath Age If Veteran of U.S. r ed Forces,
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z PI' ace of Death / ? Hospital, Instil •
• Cit ,Town or Village , Street Addr s L . : i.-
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Death rtii' to i ed / D riot Num er 1 / Register Number
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Da e e or Crem ory
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Address
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o. Date Point of
s l Transportation by Shipment
3 Common Carrier •
Destination
- 0 Disinterment
Date Cemetery Address
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Reinterment Oars Cemetery Address
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Name of Funeral Firm �a�z� �1 f a 7/ 7
• Addrbs�
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game eFunal fii•1VfaRl an om �%
i Remains are Shipped, If Other than Above
Ct Address
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Permission Is hereby granted to dispose of the dead uma` re s describe bove as Indicated.
Date issued Registrar of Vital Statistics 1
(signature)
District Number --cr‘o/ Pla ,,(..4.-- , G�� //o/I certify that the remains of the decedent identified above were disposed/ o ' ccordance with this permit on:
W y—,26--:-0Date of DispositionPlace of Disposition f i�//417/,E-4. e,/14/J�//9�f}/�lc)41
2 (address)
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CC CC (section) (lot number)) (grave number)
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p Name of Secton Person in Charge of Pr ises ,p -�
Z Pam) &� X,l///6 �- /" i;�! .
w Signature — Title /
DOH-1555(9/86)p 1 of 2(formerly VS-61) ._ . _ __