Washburn, Raymond NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
7777 i Name First rt' Middy Las
-27,-(57,c-ei 22,---e<
SP
i!iis Date of Death 1/ Ale_ if Veteran o U.S. Armed Forces,
/'4 �7 Z War or Dates /i/,
i4 Place of Death Hospital, Institutiona
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City, Town or Village tee., Street Address -' `
IiiilManner of Death To Natural Cause Accident El Homicide 0 Suicide Undeterm ned ri Pending
LiiiiCircumstances Investigation
Ill Medical Certifier Name tle
Address
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giiii Death Certificate Filed - Distr Number i Register Number
>> City, Town or Village y'� ,.-:7 VS—, i' �/3
! Date � d
II--11 / 1 Cemete r Crerry
1_1 Burial //// 7/
Address �` 4,,)
cc.ee..i ® - -mac
Date 1 Place Rm ved
0❑Removal and/or HI'd
..- and/or Address
I Hold
0 Date Point of
Q Transportation Shipment
3 by Common Destination
Carrier
Disinterment Date I Cemetery Address
Reinterment Date Cemetery Address
i
Permit Issued to /
Registration Number
Mi Name of Funeral Home ' 1C
I Address
Win 'j 4_,.
LiN Name of Funeral Firm Making Disposition a to Wh
"' Remains are Shipped, If Other than Above
Address
W
Permission is hereby granted to dispose of the human rem ns cPes bed oye asArr7Catted.
iiia
Date Issued 749 Registrar of Vital Statistics ..i --z'Ae '"",'''
(signature) ram.
iiiiiE District Number VS7/ Place _,.. � zJ / C .c
r J
I certify that the remains of the decedent identified above were disposed of in accordance ith this permit .
W Date of Disposition /J /O/c v Place of Disposition flhNE
- ��4J f',�'/ �77"i1
w (address)
0 CC (section) (lot number) (grave number)
Name of Sexto r Person in Charge of Premises . 7&I,9�f�7 � 7 27i94/
z (please print)
*: Signature Title G'/? d 53/7
DOH-1555 (10/89) p. 1 of 2 VS-61