Biddle, Mary S NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Biostatistics -Vital Records Section
Name First
Middle La% p� Sex
.�&�.. .. ..................... C�4�
Date of Death : Age / If Veteran of U.S.Armed Forces,
War or Dates
,
Z. Place of Death , Hospital,
P ^: ,. cw�cr-Village vCy:� G 2s........yl... : Stet Address... . .. :..�i ._:. :....::::: .:::::....j......::... :::::::::.: ::::::::::: :::::::. .... .. ..................... - .,....:.::...............
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Gt' Cause of Death n s
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:_ Medical Certifier Name Title
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Address .:....::..........::.......................................
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..... Death Certificate Filed District tuber Register Number
[ City-ew►r-er-Village
Date } Cismatefy-or Crematory
❑Burial ff `f g
:............................................................................................: '.....................ya /
mation Address
Z! Date Place Removed
_ ❑ Removal and/or Held
and/or Hold .............::::.....:::......_......:::.::::::::::::.:::::::::::::::::::::::::::;>::::::.:::::::.::.:::::::::::.::.:::::.::::::::::..:::::::::::::::::::::::::::::::::::::::::::::,:::::::::::::,:::::::.:::::::::::.:::,:,::::
Address
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ty Date Point of
sn+ ❑Transportation by Shipment
CommonCarrier ....................................................................................................................................................................................................
Destination
Date::::::..................................................... ...............................................
>::>:::::........................................ ......................................::.:::: .:::::::::::::.::::Address
:::.::..:::......
❑ Disinterment Cemetery
❑ ........... : :: : .....: .... ............................... . .. Date Cemetery Address ..........................................
Permit Issued to Registration Number
Name of Funeral Firm
Address
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6
5
} Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
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Address
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Permission is hereby granted to dispose of the human remains described above as Indicated.
Date Issued �i_ 1� Registrar of Vital Statistics 6xi'ue. _��-�z4
(signature)
District Number Place r
I certify that the remains of the decedent identified above were disposed of in ccordance with this permit on:
W. Date of Disposition Place of Disposition / %/�,L=!/'i.�L/ j.F/f?/4 T/:7/ 01Y1
(address)
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(s(section) (lot number) (grave number)
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>p g 4 042d,,0 42d Tif Name of Sexton or Person in Charge of Premises
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w Signature t� /�L(,d �l}t , J— Title T'
DOH-1555(9/86)p 1 of 2(formerly VS-61)