Walsh, Clinton B NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Biostatistics -Vital Records Section
Name First Mkple Last Sex
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..... . ...............................................................
Date of Death Age If Veteran of U.S.Armed Forces
�.::. ::. ........::::::::::::::::::::::::> .1>::::::War or Dates.........................................................................................................::....:::::::::::::::::. .......... ::::..::.:.::.::::::....
Place of Qeat ii Hospital, Institution or
City,Town or Village j 1 1 Street Address C� (� Q
Cause of Death �......(c......... :::.::::::.:L�...1 :Q1::::::::..f �
Medical Certifier Nl�Te Title
< > Address
Death Certificate Filed District Number s Register Number
City,Town or Village ���y `�ty��n������� ►�� `�
Dat
C torY @ e or r ma to
C
ry
Burial
Cremation ute ns V�J U ��01
M. Date Place Removed
❑ Removal and/or Held
and/or Hold ::::::::::::,:::.:::::::::::::::::::::::::::,:::::::::::::::::::::::::::::::.:::::,::;>:::::::::::::::::.:::::::::::::::::.::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::.::::::.::::::::::::::::::::..........
Address
::>......:::::;:::::::::.::::::::::::::::::::.............: ::::::::::::::::::::.::::::::::::::.:::::::::::.::::::::................... ...............................
bDate Point of .................................:...................................................:.
0 ❑Transportation by Shipment
Common Carrier
Destination
' Date::,:::..................................................... ..............................................................................................
❑ Disinterment Cemetery Address
> ba"te......................................................... ..............................................................................................
Reinterment Cemetery Address
<: Permit Issued to
Registration Number
Name of Funeral Firm::::::: .: : .\.cam Cam.:::::::: .::::::......: .:. `(.: ::.:::.q-....... .. ........... . ......... . . .. ....
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Address
�.. ........... ...._... : ... _........... ..............................._..... . _.......
Name of Funeral Firm Making Dispositiono Whom
Remains are Shipped, If Other than Above
.. ..
Address
:# :
Permission Is hereby granted to dispose of the hums remaing described above as Indicated.
Date Issued 75 Registrar of Vital Statistics
(signature)
District Number ��� `� Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
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W. Date of Disposition V '" Place of Disposition / i���'���`'cJ /! /��/e r
(address)
w
(section) (lot number) (grave number)
p; Name of Sexton �r PersoYinharge of Pre ises
Z
(please print)
)
�nt
Signature Title (�/P.c�/�.��c� l
DOH-1555(9/86)p 1 of 2(formerly VS-61)