Cornelius, Carolyn H NEW YORK 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 H Veteran of U.S.Armed Forces,
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War or Dates
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Te�rrtor Villa e
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Medical Certifier Name T,le ............................................................
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Death eCertrificate Filed C Dist' Number Register Number
or Village
Date GewiMwy or Cremato
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remation f,
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Z Date Place Removed6
❑ Removal and/or Held
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a' : Date ,...Poiritof...............................................................................................................................
(n ❑Transportation by Shipment
Common Carrier ..............................
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Destination
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El Disinterment
Date :...Cemetery Address.:.:.:...........................
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El 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 Makin Disposition or to Whom
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Remains are Shipped, If Other than Above
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Address
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Permission Is hereb granted to dispose of the huma remains descrl ed �abbve as Indicated.
Date Issued �6 q Registrar of Vital Statistics � � � Gid.L
(signature)
District Number O Place IXII 0-4
I certify that the remains of the decedent identified above were disposed of in accot ance with this permit on:
w Date of Disposition _$ Place of Disposition /{/V• �, 1 � ��� �f
(address)
tal
` (section) (lot number) (grave number)
p Name of Sexton or arson in ar a of Premi es
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W Signature Title /F 7<5
DOH-1555(9/86)p 1 of 2(formerly VS-61)