Caratsole, Martin q 1w
NEW YORK StATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
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iiii Date`of Death ; Age If Veteran of U.S. Armed Forces,
1 _ A. - :2-1 s 7 / War or Dates l C(o' - (C 7 0
E Place of Death Hospital, Institution or
Z City,Tow s or Village 41(p(j,1,j ! Street Address %Li R,',rc,vreqd D /Iwdh ,/Uy as 3f
Manner of Death fit) Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name Title
L.°,r",I ( 1 ofiv OH ( 1)i ;'vjt)
Address
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Death Certificate Filed District Number RegistNumber
City,trove r Village {- I( a IC`. ' 4 5SJ V
Date C metery or Crematory
❑Burial `� '
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[l Cremation LL.,t1 LAA bl.ta"Z A /Z_j 0 Li
• Date J Place Removed
,2 O❑Removal and/or Held
and/or Address
N Hold
O Date Point of
N❑Transportation , Shipment
a by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
'<' Permit Issued to Registration Number
Name of Funeral Home ( U.7e,r kitiveret
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Address
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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 re ins described above as indicat .
M Date Issued :ice/5 Registrar of Vital Statistics 1� ,c.�-���P ib�,� L�?
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1
(signature)
District Number <5.-- Place / r' c)i1 C f dad"?1
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
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W Date of Disposition 1Z^2q-/5 Place of Disposition dress)
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2 (a dress)
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CC (section) (lot number) (grave number)
0 Name of Sexton orPerson in Charge of Premises J u 1,C,n C . ,,ta.44.e_
z (please print)
W Signature ,0=-L ,(,t. Title Cc-8_,ssle,,
DOH-1555 (10/89) p. 1 of 2 VS-61