Dudley, Ralph NEWYORKSTATEDEPARTMENTOFHEALTH Burial - Transit Permit
Vital Records Section
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Name _first dle Last Sex
Date of Death Age If Veteran of U.S. Arm Forces
g`` a6 f �. War or Dates ..:: :... . o ...
Z Place of Death ( Hospital, Institution or
W City Town or Village /A�'Or PL) .SQl) Street Address 31/r9. eiU e. g I dq� ed
ia Manner of Death atural Cause ❑ Accident Homicide 0 Suicide r-i Undetermined Pending
Circumstances Investigation
Lit Medical Certifier Name Title
tl
Address
O.0-. . rK .fir 61eA :, riV/6 496 ) V..Sei
Death Certificate Filed y-� District Number Register Number
iiiiE City,Town or Village �G1- /n h( 5010 f,-4/
Date Cerr}yetpry or Crematorye /�
❑Burial �(!Ue...1/Lq:[ lr-l!':QA7Ufri/:_::..... ..::
Cremation Address
Z Date Plac Removed
0 0 Removal and/or Held
1- and/or Hold . ::.::
Address
a'. Date Point of
Transportation by Shipment
p Common Carrier .:::::..
Destination
0 Disinterment
Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to 4iy
Registration Number
�1.Name of Funeral Firm 1 cii.4. ... chug^A:.I..:. 1-1(),-)7 e± - fj0
Address
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 huma 1 remains des gibed above as indicated.
Date Issueda . — �/ Registrar of Vital Statistics 4.--4=0 ��A_�
[[//� (signature)
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—District Number �� N G fYt t4S W Place r:k.) I L-' /2 cra5
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z "'Date of Disposition ' /`/ 7 Place of Disposition 1"il1L' tJ;(Z IA.;) CCe,nA
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2 (address) /
wCC.
(section) (lot number) (grave number)
1
p Name of Sexton o ers n ' Char e of Premises J 10..-1 4..vi e'iv .a.-4
Z (please print)
W Signature Title L/'e--#444.0,,
DOH-1555 (10/89) p. 1 of 2 VS-61