Wilson, Harvey 55 1
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial ® Transit Permit
Name First 7Mile List Se,�c �
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Date of Death I Age I If Veteran of U.S. Armed For es,
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Place Bath H - I Institution or Ci , Town' r Village a'U6-g;aS 3 Street Addre3 3 S' 2 l t n
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Manner of Death Natural Cause Q� ent n Homicide 0 Suicide ❑Undetermined Q Pending
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Circumstances Investigation
ku Medical Certifier Name n Title
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Address
Death -: icate Filed II District Number Register Number
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'•> E Burial Date / ��2/ Cemetery c Cremato
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QEntombment! �' lk Lv �.J fir-V i b i..)
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`Cremation U OIL 61� L Q U Ars d vYu; A
k Removal Date f Place Removed
0 C and/or I and/or Held
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Address
t Hold
O Date Point of
0• Transportation P Shipment
6 by Common 1 Destination
Carrier i
Disinterment Date Cemetery Address
Reinterment Date 1 Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home 1 • L ;-�L-(--Ok:1 Hcc \
niii Address �'t �'
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`_ 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 human remai des s-indicated.
Date Issued S-l q— I (,p Registrar of Vital Statistics --0 a, j_
(signatur
District Number 5L061 Place 45u4,_ S u e_4ti o
• I certify that the remains of the decedent identified above a disposed of in accor ance ith this permit on:
LiA Date of Disposition J7.-z//(, Place of Disposition /Mt L) Ls,fc1 44 `y
2 / (addrerss)
tit
ia
l (section) 1 /A (lot numbs)_ (grave number)
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Ca Name of Sexton Perso in Charge of Premises 1 c'� 11
(please print)
14- . Signature Title e--re/n `"
(over)
DOH-1 555 (02/2004)