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Karlson, Mary NEWYORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Biostatistics -Vital Records Section Name First Middle Last Sex ........................c3/ .......: .s .! ...:.. / ca r/ .o./�..::............ . Date of Death G Age If Veteran of U.S.Armed Forces, .at`ch....., ril .,...�.9 ... .: .......7a War or Dates .. ....... ......: Place of Death Hospital Institution or �} City,Town or Village C©/� Street Address �j!!!C.h.....a�� ......../'�4�//D/ �C/� Cause of Death .. .. . .......... ............. ................................. z � .... ldd .a � ..�.. ... ..... ......Medical Certifier Name Title o` acc� .:... 2a.chrna� ... Address cG6� ................... :_ .../�/ea/ l2 Q,. er ... .. .: . . Death Certificate Filed District Number Register Number City,Tow- _a or Village �jr./CD� �'��".c� Date Cemetery or Crematory ❑Burial ` / 9�..:/ 8 ' r .: ... ........... AddressCremation ...... ..................... ... .. . QU � .(.l:/...t ...: . /t1 _..:........ ... ....: .. ....... Z Date lace Removed O ❑ Removal and/or Held E=1 and/or Hold ................::...: . .............. ..... ..:.. Address 0.:: ....................... 0. Date Point of.....:...... .. .. Ch ❑Transportation by Shipment C) Common Carrier :.....:....:...... Destination ........ .............:::.:.............. .. ❑ Disinterment Date Cemetery Address .. ........ ❑ Reinterment Date Cemetery Address. ... .. ..... Permit Issued to Registration Number Name of Funeral Firm .? :.... Address ...Q.O.../or.... :_:.......:..::: :. .. . ......... e:..... ':,..... ....���iEs5.�er:�o.W/.o .llJ.:' .... . .. ...... ... .... ........... Name of Funeral Firm Making Disposition or to Whom ' Remains are Shipped, If Other than Above ..... . ....... .................. Address t0. Permission is hereby granted to dispose of the dead human remains described above as indicated. Date Issued Registrar of Vital Statistics (signature) District Number 156 15 Place I certify that the remains of the de edent identified above were disposed of in accordance with this permit on: w Date of Disposition Place of Disposition 2 (address) J W'' ,,cc (section) (lot number) (grave number) p Name of Secton Person inAparge of Pre es � z lease print) �— W Signature Title �/� /�� ��cS/ /i DOH - 1555(9/86)p 1 of 2(formerly VS-61)