Whitney, Sr. Arthur i
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name Firstl Middle or Last Sex
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Date of Death i Age i if Veteran of U.4)). Armed Forces,
A i 9-0 - /Q , g2_ 1 War or Dates iks_A_,-)9-1,tk_ e-t9A2 CL") &ZIA
Place of Death /at I Hospital, Institution
A CO:Tts.y)Town or Village 41.0 ; Street Address ' Lita-K
Manner of Death 520
., Natural Cause 0 Accident 0 Homicide 0 Suicide El Undetermined Pending
"'"'Circumstances Investigation
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ia: Medical Certifier Name Title
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Death Certificate Filed District Number RegisterOrer
own or Village 1.1.....A...O ! (a/061 !
w._.1 Date ' meter or Crem tory
Burial
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Cremationi: Addr ss
Llia...4L.6-40GLiti-/-) I p7t)
ill
' r---I Removal :, Date
L-I t, ; ce Removed
0 I and/or Held
and/or Address
Hold
2 r-1 - -,
Date Point of
fa L j Transportation , , Shipment
5 by Common Destination
i Carrier
..„ .....„ . _
0 Disinterment I Date Cemetery Address
Date 1 Cemetery Address
.
.': E Reinterment
Permit Issued to : Registration Number
Name of Funeral Home bliti.X.A. A_LADA c:14.0wk_, \..1)--k,C,_ 0 Oca I I
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Address
...
...
Name of Funeral Firm Making Disposition or to Whom 3
„..- Remains are Shipped. If Other than IS Above
Address - ...
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Permission is herceb grantedo/ 0
: to dispose of the human r mains scribed a ove as ind- •
,,Date Issued 10 0iRegistrar of Vital Statistics
District Number >7&-
Place ,3eo i
I certify that the remains of the decedent identified above were disposed of in accordance ith this permit on:
/Place
1 t
of
Di
Date ,1
spoSiion 0 ill.lit of
rifi
Disposition -0,4 01"(Ad LitAr 1--
2 (address)
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CA
(section) (lot number) .---- (grave number)
Name of Sexton or Person in Char e of Premises
(please print)
Ai4 Signature Title Citt-i-/11 A-rOL
DOH-1555 (10/89) p. 1 of 2 VS-61