Mayforth, Catherine W NEW YORK STATE DEPAR-MENT OF HEALTH Burial - Transit Permit
Bureau of Biostatistics-Vital Records Section
< > Name First Midd Sex
Date of D Age If Veteran of U. me es,
War or Dates
F ...........................
Place of Death ? Hospital, Institution o r
City,Town or Village Street Address
C Cause of Death
ty
Name.... Tit:::::.........................................................................................................
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Addyef
eath VaMZ6 Fil ed :' DistrNum Register Number
City,Town or Village
e to or Cr atory
❑Burial
��E(dmation ::
Ad s............. 5-: , ..... ... .. . .
.. ... ..:.............:::.. .:........::.:.. ..............................................
z ate Place moved
Oi ❑ Removal d/ Held
and/or Hold[;::._:::.:...............:......::::::::::::::::::::::::::::::::.::::::::.::::::::::>.::::. ::::::.::::::::::::::::::::::::::::::::::::::::::: : ..... :::::::::::::.......:::......::::,::::::::::::::::::::::::::.::
Address
Q............:..::::::::.::::._:>:::.::::::::.:.: .....................::::::............::::::::::::::::::..................._........._._._.._...................................................................._............ .................
>t Date .Poirit of.................. ..............................
f................................................................................................................................
:0 ❑Transportation by.. Shipment
Common Carrier .............................................................................................................................................................................
Ct ..........................::...................................................................................................................................................
Destination
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❑ Disinterment Date Cemetery Address
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❑ Reinterment Date :: Cemetery Address
Permit Issued to Registration Number
X.X.X.-
Name of Funeral Firm
Address
� 1 _
��6 Fun' irm akin�iko t6ii or#= g homRemains are Shipped, If Other thaAbove
ii Address
Permission Is hereby granted to dispose of the hu an remains scr d ove as Indicated.
Date Issued — Registrar of Vital Statisti
nature)
District Number Pla
I certify that the remains of the decedent identified above were disposed of in ac ancee with this permit on:
Date of Disposition j Place of Disposition I'01(d Z !/i 14.4 �/I •�/ /9/O//`/-/�
(address)
:W,
(section) (lot number) (grave number)
'p; Name of Sexton r Person i Charge of Pre ises
Z (please print)
w Signature Title rIlf
DOH- 1555(9/86)p 1 of 2(formerly VS-61)