Skellie-Beaudet, Dorothy NEW YORK STATE DEPARTMENT OF HEALTH (12._,
Vital Records Section Burial - Transit Permit
Tii Nam First i Middle __I)..ast sp
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e e eces
:: D e - Ace If Veteran of U.S. Arm d ,
"7 , r.i I `7t) War or Dates
iH Plac . Reathl� Hospital, Institute or
City ow `or Village j' SluicLiCi Street Address 1""`40' finSn'� D/yl,$
til
a Man - of Death ytlatural Cause C Accident El Homicide D Suicide 0 Undeter ed 0 Pending
ifJ Circumstances Investigation
C
Medi al Certifier e Title
L0...141 _ ` nQ/ 1
ress
Death .ficate file Di ' t umber Register Number
City, own d Village J
_7: 03..__
4
(Date (- Cenyertyry or C matorCion
.
E Burial _ - d- — /L ittLc.c�� o
,4d ss /
:::•(J Cremation 0
Date / Place Remov d •
0 ❑Removal and/or Held
••• and/or Address
�"" Hold
Q Date Point of
flaiE Transportation Shipment
Ei by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
rrr
Permit Issued to / Re istration Number
.: Name of Funeral Horn r ( _ //,.....
dd Aress � Q�
Address/
/ J`
': Name of Funeral . Making Disposition or to Whom
•= Remains are Shipped, If Other than Above
27 Address
141
iN Permission is re y granted to dispose of the human m ins described a ve as ' dicated.
iiiiiiiiii Date Issued-7 Registrar of Vital Statisti
Iiiii District Numbe67 Place
I certify that the remains of the decedent identified a e were disposed of in accordance with this permit on:
f-
WDate of Disposition .Th-113 Place of Disposition 4? LL lrrt '*---'
M (address)
1JJ
CC (section) (lot n mber) (grave number)
O Name of Sexton or Perso n Charge of remises r.} fr,,Llifr
print)
g (please p ) �'�l'rOt
Signature Title C�
DOH-1555 (10/89) p. 1 of 2 VS-61