Vanslooten, Donna M NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Biostatistics-Vaal Records Section
Name First Middle Last Sex
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: Age ed
U o War r Dates o� c�
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Place of Death Hospital, Institution or "
Town or Village G( n Street Address � S
i:(j Cause
.U-j. Medical Certifier Name Title
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Address
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Death Certificate Filed District Number Register Number
Chit ,Town or Village 6'&z4:Q"S JqVS
Date Cemetery or Crematory
❑Burial
Cremation ; Address
ZiDate PlacelRemoved N: :.._. ..,.:..,.....µ:... .............:...................._:........
O ❑ Removal and/or Held
and/or Hold :::Address..:............................:...............:.,..:...r..n-.x,:... ,... .::....,.,....,..,,.:.v .:,,,m,.. ...m�».,.w:..v.,..,...,,.,::.w ....:...v.........
sL< Date ; Point of
[]Transportation by
Shipment
nl Common Carrier v.Destination:... v...,......»w..::......, ..». »:.:. ...,.,,.,:...,...» �M,. .»w:�Mw -.,.»m.».....................»,..:..:..,:.:...,............,..............
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Disinterment metery Address
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Reinterment Date : Cemetery Address
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Permit Issued to i Registration
Name of Funeral Firm 4L �ci'L U 7
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.................. .... . ..............
Address
} Name of Funeral Firm M ing Disposition or to hom
:ems Remains are Shipped, If Other than Above
Address
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Permission Is hereby granted to dispose of the hums re sins escribe bove as Indicated.
Date Issued a Y ¢ Registrar of Vital Statistics
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District Number Place F4t-,eo
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: /
Date of Disposition 0 /� Place of Disposition /,� y/��
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2; (address)
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(section) (lot number)_ / (grave number)
aName of Sexton r Person irl Charge of Premises Z` 174,/71f7,P /1--�Feo r�/fr4J
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Uj: (lam )Signature Title
DOH-1555(9/86)p 1 of 2(formerly VS-61)
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