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NEW YORK STATE DEPARTMENT QF HEALTHY Burial -Transit Permit
Vital Records Section 41►
Name First Middle Last
Sex
Al
Date of Death
Age
If Veteran of U.S. AAned
Forces,
of
��
War or Dates
_
Place h ,/
Hospital, Institution or
Ci , Town or ilia e L i N c
Street Address
M eath 0 Natural Cause Accident Homicide D Suicide
D Undetermined Pending
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Circumstances Investigation
Medical Certifier Name Title
Address
7 I
Death Certificate File
City,, low Village(—,(�c L . z.0—r � �
Distri Num r S
Register Number
❑Burial
Date
Ceme or Crematory
W z� 20�
C V;C.�
❑Entombment
[j]Cremation
Address
kce15�J� NSW
Date Place Removed
i
Z
❑ Removal
and/or Held
and/or
Address
Hold
Q
Date Point of
Q Transportation
Shipment
G
by Common
Destination
Carrier
Disinterment
Date
Cemetery Address
Reinterment
Date
Cemetery Address
Permit Issued to —
Registration Number
Name of Funeral Home
Address
Name of Funeral Firm Making Disposition or to Whom r
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Remains are Shipped, If Other than Above
Address
IT
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Permission is hereby granted to dispose of the human re i s descri
abov %asindicated.
Date Issued del y ( Registrar of Vital Statistics �L,
--
( e)
District Number S (� Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
l�tl
Date of Disposition lujqI15 Place of Disposition,,V,.,
(address)
W.
(section)
(lot number) (grave number)
QName
of Sexton or Person in Charge of P emises
f
�Jg
(ple se print)
Signature �/-^/ �/fA-• -- Title
� ^
(over)
DOH-1555 (02/2004)
Public Health Law Sec. 4145(2b)
01 :1022
Receipt
4
Human remains of delivered on 20
Pine View Cemetery resenting the funeral home named on burial permit
Official Funeral Directors Reg. or License #1 11,