Martin, Dorothy NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name yirst Middle Last Sex
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iiii Date of Death A e If Veteran of U.S.Armed Forces,
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Z Place of Death �/ ,/ f� ospital, Institution or
ii City,Town or Village / J �/)C G[ /' " ,' treet Address
Q Manner of Death::Il ..... .:
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a Medical Certifier Name �� /^ r? �� Title
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Death - ificate Filed District Num er egister Number
City, own .r Village tit ( (Wyse__rp-J � &-7 / Al ,7 0/3
Date "�`s` Ce ,Ntery or Crematory 9/
0 Burial / ---• / '`f "/3 f i-A-LA/ ( ) (�-t It a- -
_gatremation Address
Z Da e / Place Removed
0I' 0 Removal and/or Held
I- and/or Hold ::.:
Address
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a Date Point of
to, 0 Transportation by
p' Common Carrier Shipment
Destination
0 Disinterment Date Cemetery Address
0 Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Firm /1 ilki-d/ 41—,-
Address
it
Name of Funeral Firm Making sposition or to Whom
Remains are Shipped, If Other than Above
.::Address
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Qi Permission is hereby granted to dispose of the human remai described a•ove as indicated.
Date Issued /- I'i -/.3 Registrar of Vital Statistics`,:'(i)_ 1ar7r�- C A I I 1-y
signature)
District Number ' s- Place C &tL 1 ` j � El j2;74s
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
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WDate
Date of Disposition ''ti.'13 Place of Disposition X,NOkw C'rwetaCtu+�
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N (section) �� (lot number) � (grave number)
pName of Sexton or Person in Charge of Premis s rt)tV f hnlli-
Z' (please print)
W Signature Title C9Or►4i0(2-
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DOH-1555 (10/89) p. 1 of 2 VS-61