Baumbach, Fredrich NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Biostatistics -Vital Records Section
Name First Middle Last Sex
.:.;.;:.;:.
Date of Death Age If Veteran of U.S.Armed Forces,
>` >'> �' � 1 War or Dates
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Z Place of Death p Hospital, Instttt&m-or
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Cause of Death
`C Medical Certifier Name Title
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Address
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Death Certificate Filed istrict Numb ....................Register Number........................
-Cttr, �Village
Date �Y Crematory
❑Burial
..............:... ' '.-.::. 3 � f ::
...Address
[cremation
................................................................. ................ .............. ........ ........
.Data Place Removed
O ❑ Removal and/or Held
and/or Hold ::::::::::::::::::: :::::::::::::::::::::::.:::::::::::::::::::::::::::::>:.:::::..::::::.:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::,:::::::::::::::::::::::::::::
Address
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tLDate Point of...............................................................................................................................
.m. ❑Transportation by Shipment
Common Carrier ........................................................................................................................................................
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Destination
:Date::::::..................................................... ...............................................................................................................
❑ Disinterment ': Cemetery Address
.;:.;:.::.:::..........................................
Date:::::.....................................................
ElReinterment Cemetery Address
«« Permit Issued to Registration Number
Name of Funeral Firm
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Address ...................... ............................... ..
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Name of Funeral Firm Making Disposi ion or t IVhorn
Remains are Shipped, If Other than Above
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Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued %,10 - % Registrar of Vital Statistics r2.c.�.-,A,4-e— cx
(signature)
District Number Place
I certify that the remains of the decedent identified above wee disposed of in accordance with this permit on:
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W Date of Disposition /Z-- Place of Disposition � r�,F�//,c�4� ���/ � /�/dip?
(address)
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(section) (loot numb e) (grave number)
a Name of Sexton r Person n Charge of Premises � �9/i lvd
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(Please print)ut: Signatures Title
DOH-1555(9/86)p 1 of 2(formerly VS-61)