Mates, Helen M NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Biostatistics -Vital Records Section
Name First Middle Last SIX
Date of Death Age if Veteraan of U.S.Arm d Forces,
' ':.i p War or Dates
1
L (�
Place of Death f Hospital, Institution or
City,Town or Village Street Address
Cause of Death yhy
Medical Certifier Name n � � �a Title
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Address :. . :::::::::::::::::::.::::::::::::.:::::,,:::::::::::::::.:,.:::::::::::::::::::::::::.
..... z
Death Certificate
Register
Filed District mbar .N ....ber......................
City,Town or Village
Date Cemet or Crematnyv
❑Burial - ...... ..... ` --
Cremation
Address � .. ::. . ..:. .. :,::::::::::::::::::::::::::::::::::::::.:::::::::::::::::::
::.:::::::.:::......................................................................... ... ::::........... ::::::: .:::
Z Date Place Removed
O> ® Removal and/or Held
and/or Hold .:::::::::::::::::::::::::::::::::.:::::::::::::::::::.:::::::::::::::::::::::::::::..:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::.:::::::::::::::::::::::::::::::::,:::::::::::::::::: :::::::::::::::::::
Address
Q>::::::::::::.:::::::::::::::::::>::::::::::::.:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: :.:::::::.::.:..................................................................................
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p Date Point of............................................................................
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y; []Transportation by'. Shipment
Comm
on Carrier ::::::::.:::::::.:::.::::::.............................................::............................................................ .......................... .................:::....
Destination
.......................:::::.Date::::::..................................................... .......................................
❑ Disinterment Cemetery Address
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❑ Reinterment
Date Cemetery Address'.
Permit Issued to
Registration Numbe
Name of Funeral Firm
Address
.::::::::::::::::::::::::::::::::.::.::::::...................................... ..............�... ........ ............................ .. ... ... .................... ... . .....:............... . . . ......... . ...
Name of Funeral Firm Making Disposition or to Whore
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Remains are Shipped, If Other than Above
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Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued ;L- Registrar of Vital Statistics �✓, l -
(signature)
District Number D Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z; Date of Disposition —t,� Place of Disposition %/✓��/
w
(address)
W
(section) (lot number) (grave number)
;dl Name of Sexton or Person i Charge of Premises
Z (please print)
w: Signature Title �� �y
DOH-1555(9/86)p 1 of 2(formerly VS-61)