Warner, Martha M NEW YORK STATE DEPARTMENTOFHEALTH Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
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Date of Deat A e If Veteran of U.S.Armed Forces
9
War or Dates
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Place of Deat Hospital Institutio
W City Town or Village �1r�G Street Address
...... .........-
G Manner of Death Und rmi Pending
W at ral Cause Accident Homicide Suic de
Circumstances Investigation
... .. . ........ ....... ......:. . .... .:::. . .... _:::.
Medical C rtifier Na Title
dress
...
DYCertifi a File Districter Reg ister Number
City,Town or Village 5
D tery o r matory
❑Burial /�
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. ..remation
.........Z a Remov
O' Removal and/or He
F- and/or Hold - ...:::. ......... .:_::. .........:
.............................. .........................
Address
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a Date Point of
tn, ❑Transportation by': Shipment
p> Common Carrier .. ..............................................................
Destination
El Disinterment Date Ceme te ry A ddress
__.
............. ....
❑ Reinterment
Date....... :.:... . .::::: ..... Cemetery Address
Permit Issued to Registration Number
Name of Funeral Firm
Q
A ress
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-;: Name of urfera i a in �ispos
g; Remains are Shipped, ff Other than Above
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W:
Address
a'
Permission is hereby granted to dispose of the huma re ins scribed ove as indicated.
Date Issued Registrar of Vital Statistics
signature)
District Number Place
I certify that the remains of the decedent identified above were disposed of ' cordance with this permit on:
W'' Date of Disposition :/ " ® Place of Disposition
2 (address)
LU
rn (section) (lot number) (grave number)
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p Name of Sexton or erson in Ch ge of Premise 19 Tom'
Z lease print) ,p —
W Signature j
�� Title ,C ///CJ of Z
DOH-1555 (10/89) p. 1 of 2 VS-61