Bolster NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Biostatistics-Vital Records Section
Name First Middle Last
Date of Death Age�7 ff%Veteran of U. .Armed Forces, , 7 �
/ ` War or Dates
Place of Death Hospital, Institution
City ........ ..............................................................................`--:::::
City g
Town Village Street Address
......... .............or '..., ::::::::
f Cause of Death , ....................... ........................
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...
.. ...::: ....................................
Medical Certifier Name
IQ
..................................................::.::.......
::
-ram �� �?
Addre
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Death Certificate Fi d Dist umber Register N mbqr
City,Town or Villag
❑ CDa mat
ry
�
Burial
Cremation ........... ............: Addre s
.................
...
Z Date Place Removed
`0 ❑ Removal and/or Held
and/or Hold ..:::::::::::::::::.:::..:::::::::::::::::::,.:,::,:::::::::::.:::::::::::::::::::::::;>:::::::::::::::::::::::::::::::::::::::::::::::::.:::::......:::::::::::::::::::::::::::::......::::::::::::::._:::::::::.:.....
:::..:.::::::::
Address
0........................ ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::.....:.:::::..:..:...:.:.::.....:...................................................................... ...........................................
Date Point of. ..........................................................................................................................
N Transportation by Shipment
Common Carrier ..................................................
Destination
.............................:::::Dat ::........................................................ ..........
Disinterment a CemeteryAddress
.. ;: . : .
....... ........ ......................... . . .. ...... : Date: Cemetery Address ..
1-72
Permit Issued to Registration Number
Name of Funeral Fir ���
Address ��
....... ..........................
:°'�°'� Name of Funeral rm Makin Dis sitio r Whom 1....................
Remains are Shipped, If Other than v
,.:::::::::,:::::::::::::::::::::::::...::::....................................................................................................................................................................
....................................
Address
Permission Is r y gr ted to dispose of the hu n r mai 'described as�Ind.
i
`> Date Issued Z Registrar of Vital Statistics '
ature)
District Number Place
I certify that the remains of the decedent identified abgive were disposed of in ace rdance with this pen t on:
ua:
Date of Disposition Place of Disposition e7/
(address)
;w
,tr
(section) (lot number) (grave number)
M. Name of Sexton or Person in har a of Premises
Z Signature ��)Title
DOH-1555 (9/86)p 1 of 2(formerly VS-61)