Mead,Milton S NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Biostatistics -Vital Records Section
Name First M' le List Sex
Date of Death Age ff Veteran of U.S.Armed Forces,
War or Dates
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Place of Death Hospital, Institutio r
City,Town or Village Street Address `
':> Cau...........se of Death
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Medical Certifier Name Title
Address
Death Certificate Filed District Number ................ 'Reg'istet Number.......................
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City,Town or Village Az' g&,
Date Cemet ry or Crematory
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❑Burial
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<:;::» � Address ................................................................ .................
Cremation
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Z Date lace Remoged
Q:: ❑ Removal and/or Held
� and/or Hold :::::::::::::::::::::::::::::::::::::::::::::::::::::::::.::::::::::::::::::::::::::::>::::::::::::::::::.::::::::::::::::::::::::::::::::::::::::::::::::::,::::::::::::::::::::::::.::::::::::::::::::::::::::::::::::::::::::::::::::Address
t] Date Point of
v Transportation by` Shipmentp C ....
................................................ . .. .
Common Carrier ::::::::::::.::::::::.............................................::................:.....::.::
Destination
Date::::::..................................................... ..................................................................................................
Disinterment Cemetery Address
Date:::::..................................................... ..................................................................................................
:.......................................... ........................... ...................................................................
Reinterment ' Cemetery Address
Permit Issued to Registration Number
Name of Funeral Firm O��
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Address .................................
:: :::. ..........
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Name of uneral Firm Making Disposition or to Whom
"' Remains are Shipped, If Other than Above
'�':....Address........................................................:.............................................................................................................................................................................................
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Permission Is hereby granted to dispose of the h718
vemai described ove as indicated.
Date Issued �� S� Registrar of Vital Statistics
signature)
District Number Place
I certify that the remains of the decedent identified above were disposed of in ac rdance with this permit on:
Z' Date of Disposition Place of Disposition " /1�.t�� O
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g (address)
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(section) (lot number) (grave number)
pi: Name of Sexton Qr Person 'Ai Charge of Premises
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print) 7'Z Signature cy Title T/Q
DOH-1555(9/86)p 1 of 2(formerly VS-61)