Elmendorf, Alexander H NEW YORK STATE DEPAR-IMENT OF HEALTH Burial - Transit Permit
Bureau of Biostatistics -Vital Records Section
? Name First M' Sev
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Date of h e If Veteran of U. rmed Force
War a
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or Dates
Place of Death / :: Hospital, Institution
City,Town or Village _ /� Street Address
:I ...Caus Death
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art'ier, Na dle
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Ceate le ,F / District Number : Register Number
City,Town or Village j
❑ rem ':. AD�a�ress ,�te ,i�
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C=a1s ly or Crematory
Burial
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ation �� ��'...i...U..�...�.....,...�...„...�
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M. Date Place Removedf
Q ❑ Removal and/or Held
and/or H ..................................................................................................................................................
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Address
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1 Date Poirit of................
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cn ❑Transportation by; : Shipment
Common Carrier ......................................................................................................................................
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Destination
ate:..........................................................
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❑ Disinterment
D Cemete Address
Date:::::..................................................... ... . .......................................................................................................
❑ Reinterment
Cemetery Address
Permit Issued to / Registration Number
Name of F-
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re
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'Name cfFun ra akin Di or hom
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:-Z:: Remains are Shipped, If Other than Above
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Address
Lt�l
Permission Is hereby granted to dispose of the hum ordains ascribed ova as Indicated.
Date Issued �' ,� Registrar of Vital Statistics
signature)
:> District Number Place
I certify that the remains of the decedent identified above were disposed accordance with this permit on:
z< Date of Disposition jy'Place of Disposition
w
(address)
w_
(section) (lot number) (grave number)
p Name of Sexton arson in arge of Prer ises
Z print)
w Signature ease int Title L—/�� f'7 ��/
DOH-1555(9/86)p 1 of 2(formerly VS-61)