Clarke Jr, Bernard t 3 I 0
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
nard S Clar kc, R. Male
Date of Death Age If Veteran of U.S..Armed Forces,
r— IL/- I Li- ,5 a.War or Dates K o r- vx
1 Place of Death b Hospital, Institution or
City.d r or Village 'J`_ n l C Street Address
Manner of DeathR-A Natural Cause Accident Homicide Suicide Undetermined Pending
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Medical Certifier Circumstances Investigation
i ?am
icee Title J'oe._. MIb
Address
my.::.,,
Death Certificate Filed ( District Number Registgr Number
City, '�.r Village S z nJ � � 5(caR /
Date _ C etery or.crematory
El Burial I 5 1 -i 4 f i..h C V1.e 0 � *
r Address fY
51Cremation �ufc-nsbu N
Date Pace Removed
g❑Removal ! and/or Held
and/or Address
5 Hold
O Date ' Point of .
5L:),Q Transportation Shipment
O by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
1 Permit Issued to Registration Number
a Name of Funeral Home ( p/?2� rk 0112.11
Address DIM/Lid)Id) -C La kQ__ ___ 1 ic= S o
,` Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped. If Other than Above
Address
Permission is hereby granted to dispose of the human ains described above ' d'cated.
'; Date Issued 5--/S') Registrar of Vital Statist y.X ,�
? �?(s��ignature)
District Number 56SS Place I D Of &ni
y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition Si1(-1q Place of Disposition 'f ejt/ ) Coi►etdc'"...
2 (address)
ill
N
CC (section) // (lot number) . (grave number)
d Name of Sexton or Perso in Charge of Premises
,�� +`f
z (please print)
W Signature Title CO(04 KV
DOH-1555 (10/89) p. 1 of 2 VS-61