Graves, Margaret NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name gil /F� Middle Last Sex
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Date of Death Age If Veteran of U.S. Armed Forces,
! �f I� CPC2 War or Dates /G�
Place of Death Hospital, Institution or
City, ow. .r Village �c�A,7J-,,j✓ ,l Street Address A7o e/ ./V/tr.:>,- / 7 drte 4t/�C,
t Manner of Death Natural Cause ccident El Homicide ❑Suicide ❑Undetermined 0 Pending
Circumstances Investigation
Medical Certifier Name Title
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Death Ce �cate Filed District Number Register lumber
I: City i_w r Village V cJ)/-2_s—, ., _ -Lv a
Date / Ger►etery or Crematory
❑Burial /��� A6 /1. 7 �//,"1 Q. a- � 1-�e cs7-7" 7c%V sy,
Address �� ,,
:::::. remation C�t'l/•P_P/'J.Sc/!/ �(/X/
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Date Place Rew(oved
Z❑Removal and/or Held
..• and/or Address
6" Hold
to
0 Date Point of
05 Q Transportation Shipment
. a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
''s3 Permit Issued to ��! � /�� Registration Number
iiiii: Name of Funeral Home 4`ijy/ 1� C�ff�%"�//?L?�4�/ d ".
'I Address
7 .2,7-2 4e.:C-17 .C-- c-,- 7/ r .7- /
s< Name of Funeral Firm Making Disposition or to Whom
'" Remains are Shipped, If Other than Above
address
lx.
iiiiiiiii Permission is hereby ;anted to dispose of the human remains described above as indicated.
Date Issued// � Registrar of Vital Statistics
signature)
€ District Number\3t3- Place
that the remains of the decedent identified above were disposed of in ac dance with this permit on:
I certify p t
6 Date of Disposition/2'/'?7 Place of Disposition Pit HEj f �/Y)// 7"C/1 /1 /(/�
• (address)
furl
CC (section)/ �7 (lot number) _ (grave number)
GName of Sexto or Person in Charge of Premises .5-1,4 /7 1 A4/9 7,? 6714.
(please print) SS i /—
W Signature .. Title G`/� 7—./1 / /'� /
DOH-1555 (10/89) p. 1 of 2 VS-61