Menke, Charla NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Biostatistics-Vital Records Section
Name First Middle Last Sex
Date of Death Age !f Veteran of U.S.Armed Forces,
War or Dates
:Z: Place of Death Hospital, Institution or
CityT�TtSrViila ee Street AddressC-
................
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> Cause of Death ^/ pFs
Medical Certifier_... Name it le
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n
Address
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Death Certificate Filed District Number Register Number
City,T-ewi*.w Village 1�_—,c,\C'- G
;. Date Cemetery or Crematory
❑Burial =3 c6 + c` q
Cremation
Address
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Zi Date ; Place Removed
.0.. ❑ Removal and/or Held
and/or Hold ::::::::::::::......::::::::::::::::::::::::::::::::::::::::.:::::::::::::::::::::::::;>:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::,:.::::::::::::::::::::::::::::
Address
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:::...:::::.::.:................................................................ ......................................................... .....
DatePoint of.....................................................................................................
Ni ❑Transportation by Shipment
Common Carrier ...................................................................................................................
0 ::::::::::::.........:::::::........... :.................. .....
Destination
Date::::::..................................................... ...................
................................
❑ Disinterment
Cemetery Address
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❑ Reinterment
Date ': Cemetery Address
Permit Issued to Registration Number
Name of Funeral Firm .--------- ...... :.wL........._........... :C�..c�.. i.:3._.
Address
::::: .: ::::::.::::: :::::: ::: ::::::::::::::::
Name of Funeral Firm Makin Dis sition or to Whom
Remains are Shipped, If Other than Above
Q.
Address
i0.. ........................................................................ .................................................................. ..
.::.:::................................................................................................................................................ ..::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::
Permission Is hereb granted to dispose of the h described ov as Indicate
Date Issued Registrar of Vital Statistics
(signature)
District Number Place �`c �'k �C.c
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
po F'.'IV, o `,F� c,�,c�Wr9 Tom
Z Date of Disposition U? 524-' Place of Disposition;w T
(address)
W.
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Iz
(section) (lot number) (grave number)
a: Name of Sexton Person ' Charge of P emises
(please print)
nt p I/ -�
W Signature Title �i/1 �C4) �S✓`/�
DOH-1555(9/86)p 1 of 2(formerly VS-61)