Selman, Samuel T NEWYORK STATE DEPARTMENTOFHEALTH Burial - Transit Permit
Bureau of Biostatistics -Vital Records Section
Name First Midd Last Sex
Date of D Age If Veteran of U. rm�orces,
> ' War or Dates >
Z, Place of Deat ! Hospital, Institution o,
City,Town or Village - Street Address
f Cause De th
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Address
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Dis ' t Number Register Number
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City,Town or Village
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e or a ato
ry f��
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Burial
V] srt ation
s
Z; Date PI Re ed
O ❑ Removal d/or d
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and/or Hold
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........
;: Address
Date Point of
t []Transportation by
Shipment
a; Shi ment
. ....... .... .......Carrier ... ......... ...... ..... .. ............
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Destination
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❑ Disintermentress
' Date Cemetery Address
❑ Renterment : Date Cemetery Add
<: Permit Issued to Registration Number
Name of Funeral Firm
Address
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:...... ... �
ame of4U � irm aki spcsitio ho Remains are Shipped, If Other than Above
Address
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Permission Is hereby gran d to dispose of the hu re ains es abed above as indicated.
>' Date Issued - Registrar of Vital Statistic
signature)
District Number `r Place
I certify that the remains of the decedent identified above were disposed o in rdance with this permit on:�
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Z Date of Disposition �� Place of Disposition �
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ul: (address)
>w
(section) (lot number) (grave number)
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. Name of Sexton Person'n Charge of P emises � � A
Z (please print) �i1
Signature Title Z�/mot 7(:5�i` .�✓/
DOH-1555(9/86)p 1 of 2(formerly VS-61)