Bode, Elsie NEWYORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Biostatistics -Vital Records Section
Name First + Middle Last Sex
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Date of Death Age �i/ If Veteran of U.S Armed Forces
Nov..
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Z Place of Death Hospital, Institution or
} City,Town or Village. O Street AddressY.
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t Cause of Death
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Medical Certifier4-me t Title
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Address ........ .... .........:..........
Death Certificate Filed_ i District Number Register Number
9
City,Town or Village (p��„ � ,C {���(„ � �7
Date Cemetery or Crematory ,
ElBurial ......... ......... :... ,,// . .. co.rvnc&,*..e
Cremation Address
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Z' Date Place Removed
O ❑ Removal and/or Held
H' and/or Hold ...................................................
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0. Date Point of
NI ❑Transportation by Shipment
C3 Common Carrier ................:.:...:.........:....... ..:.,..
Destination
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❑ Disinterment
Date Cemetery Address
❑ Reinterment
Date .. Cemetery Address
Permit Issued to Registration Number
Name of Funeral Firm
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Address m.. T.
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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 hereby granted to dispose of the dead ma remains descrIbA above as Indicated.
s Date Issued 1/ gp� Registrar of Vital Statistics
(signature)
District Number 7 Place Ge4rAO V/ CIV Ck, /(/
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
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cc (section) d(lot number) (grave number)
pName of Secton or P rson in Charge of Premi esJ4//9/P�
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W Signature Title
DOH- 1555 (9/86)p 1 of 2(formerly VS-61)