Hay, Roland T NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Biostatistics -Vital Records Section
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Date of Death pc� Age If Veteran.
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Place of Death Hospital, Institu '
City,Town or Villag �Q Street Address
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Medical Certifier Name Title
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Cremation : Address
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,Z Date Place Removed
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Address
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(fi, []Transportation by Shipment
CommonCarrier .....................................................................................................................................................................................................
Destination
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Disinterment Date Cemetery Address
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Cemetery Address
Reinterment Date
Permit Issued to 'Fro .. . ....
Registration Number
Name of Funeral Firm
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Address
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Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
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Address
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Permission is h reby granted to dispose of the dead human remains des be above indicated.
Date Issued kk Registrar of Vital Statistics
(sign )
District Number s7 Place P�V
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition Place of Disposition e �c4 7- «1 C 11 r- �/I
(address)
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(sectio (lot number) (grave number)
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aName of Se !:n r P rson in Ch remises
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Signature Title ;5v pj-
DOH- 1555 (9/86)p 1 of 2(formerly VS-61)