Varno, Hazel D NEW-*YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name Middy List Sv/ ex--
Date ea Age „/ If Veteran of Armed Forces
d(j War or Dates
Place of Death Hospital Institution or
City Town or Village Street Address
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Manner of Death n eter fined Pending
Na ural Cause Accident Homicide uicide
Circumstances Investigation
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ijaf dical Cert'er me Title
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Addr s J...„'.
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Death Ce ate Filed istriet er Register Number
City,Town or Village /
D ete o ematory
❑Burial
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ation Ad r
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Z ate lace Rem ed
O Removal and/or d
F- and/or Hold ' ........ .:...::..:::.. ....... .......:.......
. Add.erss a Date Point of
N',' ❑Transportation by: Shipment
plCommon Carrier ..... . . ..:.:.... _.:.: . .................................. .................................................
Destination
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Disinterment Date Cemetery Address
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Reinterment Date Cemetery Address
Permit Issued to R Registration Number
Name of Funeral Firm ���%
Addre s
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t-- Name o F neral firm a i is sit on or to W m
Remains are Shipped, If Other than Above
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. ...Address _
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Permission is herebyranted to dispose of the hu ...n. rema' ,f escribed .above as indicated.
Date Issued Registrar of Vital Statisti s
(signature)
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District Number Place
I certify that the remains of the decedent identified above were dispose fin accordance withthis permit on: . I
Z Date of Disposition pY Place of Disposition 9/J1t/ ��/ � �l�h�✓/��1��/L/�
M> (address)
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N'' (section) (lot number) (grave number)
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p' Name of Sexton o erson in C ar a of Premis s
Z lease print)
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Signature Title T
DOH-1555 (10/89) p. 1 of 2 VS-61