Campbell, Ethel NEWYORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Biostatistics-Vital Records Section
Name First Middle Last Se
'<? Date of Death Age If Veteran of U.S.Armed Forces,
<< War or Dates
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Place of eath� ; Hospital, Institution or f
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City,Town or Village a Street Address
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Medical Certifier Ine Title
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City,Town or Village ✓� o
Date
Cempumv or Cremat
ry
❑Burial
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Cremation :'
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>Zi Date Place emoved
a ❑ Removal and/or Held
and/or Hold ......
Address
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itDate Point of .......................................................................................... .....................
W El Transportation by Shipment
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Common Carrier
Destination
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❑ Disinterment ..........
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171 Reinterment Cemetery Address
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:> Permit Issued to Registration Number
Name of Funeral Firm
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Address
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Remains are Shipped, If Other than Above
Address
Permission Is hereby granted to dispose of the human re ains described above as Indicated.
Date Issued Registrar of Vital Statistics
(signature) y�
District Number Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition � `g Place of Disposition
(address)
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(section) (lot number) (grave number)
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a Name of Sextori Person il harge of Premises
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`W Signature Title !,� /Yl /d1f 2 Z
DOH-1555(9/86)p 1 of 2(formerly VS-61)