Williams, Esther K t
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Biostatistics -Vital Records Section
Name First Middle Last Se
:.:
of Death < Ae If Veteran of U.S.Armed Forces
Date ,
9
cat.
ii War or Dates
Place of Death Hospital, Institution or '
City,Town or Village y, Street Address
a € Cause of Death n
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oe
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Medical Certifier Name Title
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»» Address
Lc-a.,rn-i
Death Certificate Filed �p District Number R isterNu
mber
City.Town or Village
Date Cem or Crematory —'
»> ❑Burial
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::::::t:.....:::.::... .:.::.::. ::::::::::::::::::::
remation
Address
r
::z Date Place RemdVed
C} ❑ Removal and/or Held
and/or Hold :::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::,.::::: :::::::.....:.....::::::::::::::::::::::::::::.:::::::::::::::::::::::::::::::::,:.::::::::::::::::::::::......:::
Address
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p Date Point of
b
[]Transportation y` Shipment
Common Car
rier ::' ..........................................................................................
Destination
:: ::::::...................................................................................................
Cemetery
ry Address
❑ Disinterment Date
........ .....
Address:::::................................ ......... .............................................
❑ Reinterment ' Date Cemetery
Reg
istration Number
<: Permit Issued to 9
Name of Funeral Firm •�...
.....
:...................................................... ..............................
Address
l'
i ...._........
XXXX
Name of Funeral Firm Making Disposition or to W om
Remains are Shipped, If Other than Above
.::........::.:::::::::::..:.............................................................................................. .
Address
Permission Is hereby ranted to dispose of the human remains escribed above as indicated.
Date Issued Registrar of Vital Statistics
(signature)
District Number � e7 Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
`w Date of Disposition 2.acZ Place of Disposition �✓����71 ZF/
(address)
(section) (lot number) (grave number)
p: Name of Sexton or Person in C arge of Pre ises
Z. (please print)
w Signature Title
DOH-1555(9/86)p 1 of 2(formerly VS-61)