Vincent, Ruth NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name i to fiddle Oatst.
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Dateyft eeatth 1 U( � A If Veteran of U.S. Armed Forces,
—I War or Dates
1 Pla eath Hospital, Institution o�
Ci , Tow_ or Villag3 , Street Address f f
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0 Man of Death qNatural Cause ❑acident 0 Homicide 0 Suicide ElUndetermined r7 Pending
0 Circumstances Investigation
W Medical Certifier Name Titl
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Address � �� � � n ,�
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RitEntombment Address
remation k�3���
Dail' Place Removed
❑Removal and/or Held
and/or Address
I Hold
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0 Date Point of
C0 Transportation Shipment
ea by Common Destination
Carrier
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El Disinterment Date Cemetery Address
•
Date Cemetery Address
Q Reinterment
Permit Issued to �- / Registration Number
Name of Funeral Horr> �.�5,�.>r— ,_Aner., 4DMe L . U o 8-
,Address 7 hcr,r, /2vc ::,r= (- N,r (at �-
Name of Funeral Firm Making Disposition or to Whom i 1 Remains are Shipped, If Other than Above
2 Address
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"` Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued l d j 3LL Registrar of Vital Statistics 2 ° 1jA.i.. AV,e- .
(signature)
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District Numbe PlaceOG,,,_.-tr‘ a c C.,>)LA--.32--a-Aia.
I certify that the remains of the decedent identified above were disposed of in cor nce with this permit on:
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til Date of Disposition 143h./ Place of Disposition eUkyi (.,-
(address)
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1.0
(section) �/ (lot numbs) (grave number)
Name of Sexton or Person in Charge of Premises `, ...\h'"i
Z (lease print)
JI Signature Title cviewintoc
(over)
DOH-1555 (02/2004)