Mitchell, Timothy M NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Biostatistics Vital Records Section
Name First S Middle Last 9x Y,
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Date o eat Age ran of U.S.Armed Forces,........fiJ
War or Dates
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Place f Death Hospital, Institution *1 City,Town or Village Street Address
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Cause of Death
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: -": Medical Certifier Title
A
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Addresi-"
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Death Certificate Filed District Number Register Number
City.Town or Villa
Cem C t Date et!��pr rema ory,
0 Burial
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remation
Address
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Date
Place
El Removal
and/or Held
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and/or Hold .
Address
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Date Point of
.16 Transportation by
Shipment
Common Carrier .......... . ..... ... ...... ........ ....
0. ........ ........ ................ ..........
...... Destination
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...... Date Cemetery Address
in Disinterment
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Cemetery Address
Date
El Reinterment
Permit Issued to Re
ist ration Number
g
Name of Funeral Firm
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Address
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:44 Name of Funeral Firm Making Disposition or o.
Remains are. Shipped, If Other than Above
Address
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'i� Address
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Permission Is hereby granted to dispose of the human remains described above as Indicated
Date Issued Registrar of Vital Statistics
(sign")
District Number 3 D r Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ujDate of Disposition
Place of Disposition 'P/ /q
. '
(address)
tLj
M
(section) (lot number) (grave number)
Char of Prer
Name of Sexton r Person in nises 4 .9"IP Al zl 7
b.
WZ.L
(please print)
-5 7-
Signature Title V 45
DOH-1555(9/86)p 1 of 2(formerly VS-61)