Steves, Philip NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First. Middle Last Sex 6'i/A/.. '........ ... ..::.... ...:......:....:/a/• "T
.... .....:: ...:. seVE:g / _1/9,4 4
Date of Death Age If Veteran of U S Armed Forces,
_
®CSC. A g 1 Q/l d.. ov.S' War or Dates NO
Place of Death Hospital, Institution or
�„f Cit ow, or Village Poorr ql/ Street Address hpy../ CoG/NT � re".%fro
........, ....... ....... .. ......... ........ .. .. .y..... ... .. ..
.. Manner of Death 2 Natural Cause ❑ Accident Homicide Suicide Undetermined ❑ Pending
Circumstances Investigation
it Medical Certifier ,. Name Title
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Address
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Death C-rtificate Filed District Number •• Registe umber
City 41t15hr Village FOR r# -�/A/ S7S9
Date Cemetery or Crematory i
0 Burial ,l .:: 3-.. .01/:.. : .....::: /// U/ aJ...G`Il )7?/7/ 0/Q/L/Ili , ...
Cremation Address
L~�`NS 03eee2y Ai •
z Date lace Removed
OI', 0 Removal and/or Held
H and/or Hold
Address :..: _:.:.....:........ .:
a Date Point of
N 0 Transportation by Shipment
pl' Common Carrier
.::.. :::::.....:.::
Destination
Disinterment Date Cemetery Address
............................................. ............................ . . . .. . . . ......... . .......... .... .......... .... ...................................................................... ..................................... ...... .. .... ............... .........
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Reinterment ate Cemetery Address
Permit Issued to 1 Registration Number
. .:.Name of Funeral Firm:./7 S'ON, .F4/11 ?1L- /k'?n& , Q///
Address
.0o 630 x & 7 2 I d G E R6& S,, ,oe4 7 SIN m / /-?d 7
>- Name of Funeral Firm Making moos'ion or to Whom
Remains are Shipped, If Other than Above
w:
Address
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Permission is hereby granted to dispose of the human remains described a e,a1 indicated.
Date Issued 14/2i/-61// Registrar of Vital Statistics ..... ' -/
-, (sign ) I
�District Number - 7S� - -7� ✓Place i /-
i_
I certify that the remains of the decedent identified above were dispos of in accordance with this permit on:
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Z Date of Disposition Q€C IN tot( Place of Disposition gm O'tt..) Crier+rti"-
2 (address)
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NCC (section) (lop umber) (grave number)
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p' Name of Sexton or Person ' Charge of Prem. es 46;i-74 /M-
Z (please print) _W Signature Title Ce1E Aid'_
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DOH-1555 (10/89) p. 1 of 2 VS-61