Christie, Walter _, V
NEW YORK STATE DEPARTMENT OF H LTH
Vital Records Section Burial - Transit Permit
Name Fi1/1
/ Middle Last T Se
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i 1 �7/5/7�.
Date of Death Ol Ag If Veteran of U.S. Armed Forces,
t?iy War or Dates
Vacof"D athHospital, Institution o , ,��Town or Village oda771srq/z Street Address 60 S/97:,..././,,---)7,i-
Z0 Manner of Death Natural Cause cident Homicide Suicide Undetermined ing
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® Circumstances 1. 1 Investigation
W Medical Certifier Nam , Title
/7//s .-e/ sire .-
th Certificate Filed District N� Register Number
Ci , Town or Village �1/7g- ,�/ ��� 57�
Burial Date r Cr tdry
❑Entombment ��/'�/� ' d z.-�/e� �� .��1/ '
Address J
; remation cPi ' h� /}�,9� i% ' 7/
Date �" Place Removed
Z Removal and/or Held
P- ❑and/or Address�
IA
Hold
0 Date Point of
950 Transportation Shipment
0 by Common Destination
E. Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to / �� Registration umber
Name of Funeral Horn /G��` d// �� �iC /
Address 7 Pi/-1 ,s----/ C1 _C-1/74c)e-e.94 7 / J /7
glio Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
;'; Address
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9" Permission is hereby granted to dispose of the human r mains described oveassindi,ated. �
Date Issued /�///2O Cj�
/� Registrar of Vital Statistics P�., c '/l• A OPi,C
i ature)
District Number r60/ Place G2
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k
ILf Date of Disposition)a---'Il le Place of Disposition pi pt., V.;e„' Cte MC jocY
(a dress)
ILt
co
ilk (section) (lot number) (grave number)
CC
0 Name of Sexton or Person in Charge of Premises J- rm e,Y Sci)t;C'
z (please print)
ILI
Signature J Title GTeir4 C
(over)
DOH-1555 (02/2004)