Lee, Eugene J NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Biostatistics - Vital Records Section
Name First Middle Last Sex
A �--...:....:...................................................:.............................................................:.
Date of D ath / L Age If Veteran of U.S Armed Forces,
Zl�v War or Dates A) 0
E-.. ..............:....................... ..... .. .:.....
Place of D afh Hospital, Institution or
City Taw or�Cjlhge Street Address..............................................d"111 '
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m Cause of Death
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Zi Medical Certifier Na Title
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Address
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Death Certificate Filed District Number Register Number
City,Tewrr-or +ege
Date Cem or Cremator
El Burial Z l � T,
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[Cremation Address
> /A I ry
................. .. ...... .........
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Z Date Place Removed
O: ❑ Removal and/or Held
1- and/or Hold:
.............
Address
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G: Date Point of
:0 _]Transportation by.. : Shipment
CommonCarrier .....................................................................................................................................................................................................
Destination
...................................:..................................:........ -........... :..................................::.::::::.:.:.::.....:...................................:...:.::::...::.........
❑ Disinterment Date Cemetery Address
..
❑ Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Firm v.-ca z=-�_ _ z- C ((� �. - 9
Address
Name of Funeral irm Making Disposition or to Whom
Remains are Shipped, If Other than Above
............... ... ................................. ......... ....... ........ . . ...... ... ......... ...............................................................
Address
Permission is h reby ranted to dispose of the deed hU an remain 'described above as indicated.
<` Date Issued 2 Registrar of Vital Statisti s
ignature)
District Number s O Place �-
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition o2� Place of Disposition y�� �/�' C �Fwl�l 7elp/ (/
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(address)
W!' (section) (lot number) (grave number)
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.0. Name of Secton o Person in arge of Prises
Z, (please print) n
W Signature Title
DOH- 1555(9/86)p 1 of 2(formerly VS-61)