Casperson, Mary C NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Biostatistics-Vital R rds Section
Name First , Middle Last
.......................
` Death Age-,— Veteran of U.S.Armed Forces,
<':::::::::::::::::. :::::::::::. ..: : .. ........War...........................
E ...................................................:...........:.....:::::::::::::
Place of Deat ..........s...ita tion..o f.........
City,Town or Vill ge Street ress
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Cause of Death
..ems Medical Certifier Name - Titl
44
::>::.. .................................... Addres.
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. ..................... .....
............ ............... .........................
Death Certificate
..
ertificate Filed District NumberR i r Number
City,Town or Villag J 2)/
DateCemetery story
f
❑Burial
b .:.................................>... ..... .........
emation
Address .... ......... : ::::,.,.,:::.::::::::::::::::::::::::::::::.:::,
Date:::::.................................................................. ..... ..................................................................
Z PI ce Removed
Oi ❑ Removal and/or Held
and/or Hold ::::...........:: :::::::::::::::::::::::::::::::::::::::::.::::::::::::::::::::::::::::::::::::::::::::::.::
r Address
f3 ' Date Point of................................................................................................................................
V) []Transportation by`: Shipment
Common Carrier .............................................................................................................................................
d ::::::::::,:::::::::::..:.:......................... ::........................................................ ........................................................................................
Destination
Date
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❑ Disinterment t Cemetery Address
Date .:::..................................................... .........................................................................
c...:..:
..... ..... .... . ......... ...............
❑ Reinterment emetery Address
Permit Issued to Re istration Number
Name of Funeral Firm
r�J��
Address
Making ame of Funeral Firm Disposition
osition.or to Whom:::.:.......................................................................................................................................................
9
Remains are Shipped, If Other than Above
>�� Address
Qr
Permission Is h eb granted to dispose of the human r in491"
as dicated:
Date Issued t 3 Registrar of Vital Statistics
(kignature)
District Number Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition Place of Disposition P�
(address)
'tULL
(section) (lot number) (grave number)
. I� s�/t�IJ /Y� T/t�i9lc1 p Name of Sexton Person ' Charge of emises
U (please pent)
Signature Title /f
DOH-1555(9/86)p 1 of 2(formerly VS-61)