Martin, John T NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Biostatistics -Vital Records Section
Name First Ndle last Sex
....�r,J
Date of Death : Age ` If Veteran of U.S.Armed Forces,
War or Dates hU
E-: ` .......................................................::.::,::::::.:::::::::
Place of Death Hospital, Institution or
: .: City,Town or Village :::::.:. .:.:::::::::.:::::::::Street Address....................... �-y-®
f� Cause of Deathf
::.: _:::::::: ::::,,::..:::. ::::::::::::, :::.:::::::::.:.,:::: ................... ...............................................................
Medical Certifier Name 0.
Title...........................................................................................................
-.
Address
Death Certificate Filed District Num e � : Register Number
City,Town or Village
Date Cemetex4r1crernafory
❑Burial
�remation Address /'f
................... `.::::................................. ............ y,
...........
z Date Place Removed
0i ❑ Removal and/or Held
and/or Hold :::::::::::::...:::::....:......:::::......:::::::::............::::::.:_:::::::::::::;:.::::::::::::::::::::::::::::::::::::::::::::::......::::::::::::::::::::::::::::::::::::::,:::::::::::......:...... :::::::::::.:::.:..........
Address
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aDate Point of ...........................................................................................................................:.
N'; []Transportation by:.
Shipment
CommonCarrier .........................................................................................................................................................................................
Destination
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❑ Disinterment Date Cemetery Address
................................::.....................................:.:..................
.............:..>:.::..:..,.............
❑ Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Firm
'~
Address /
U�
i
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, ff Other than Above
PP
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Address
Permission is he777
granted to dispose of the human remain described above Indicated.
Date Issued Registrar of Vital Statistics
signature)
District Number v Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
.
w Date of Disposition :/ 1" Place of Disposition P/�•��/ tom (c>
'i (address)
w
(section) (lot number) (grave number)
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a Name of Sexton or Person i Charg a of Pr ises �'044f��
Z. (please print
W Signature Title
DOH-1555 (9/86)p 1 of 2(formerly VS-61)