Hoag, Robert J NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Biostatistics -Vital Records Section
Name
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War or Dates
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Address
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D th Certificate Filed r :: District Number Register Number
(IC!W,Town or Village
Date C"ry or-Crematory
urial
Cremation
Address
Z> Date ace Removed
❑ Removal ': and/or Held
and/or Hold ::::::::::::::::::::::::::::::::::::::,:::::::::::::::::::::::::::;>:::,,:,:::::::::::::::::::::::::::::::::::::::::::,:::::::::::::::::::::::::::::::::.:::::::::::::::::::::::::::::::::::::::::._::::::.::::::::,::
Address
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........................................................................................
G Date Point of
)f ❑Transportation by Shipment
Common Carrier :> ..................................................................................
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Destination
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❑ Disinterment Date Cemetery Address
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❑ Reinterment Date Cemetery Address
>: Permit Issued to Registration Number
Name of Funeral Firm
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Address
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Name of Funeral Firm Making Disposition or to , om
Remains are Shipped, ff Other than Above
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Address
Permission Is hereby granted to dispose of the h7:ignature)
emains described above as indicated.
Date Issued Registrar of Vital Statistics �— 2
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District Number G / Place `C�.iz `G �/• G � ��
I certify that the remains of the decedent identified above were`�disposed of in accordance with this permit on:
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Z' Date of Disposition �7 Place of Disposition ^i
lUJI (address)
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(section) (lot number) (grave number)
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p: Name of Sexton arson in ar a of Pre es
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14
w Signature Title Q,,,r j
DOH-1555 (9/86)p 1 of 2(formerly VS-61)