Hayes, Clark NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Biostatistics -Vital Records Section
Name First Middle x
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Date of Death Age H Veteran of U.S.Arm Forces,
::
War or Dates
Place of Death Hospital, Institution or
City,Town or Village .. Street Address
Cause of Death �, ���� -.::.................. ...:...:....
.. :..... .....:::.:::::.
3!. ..............................................................
..........:::::::
ti~# Medical Certifier Name Title
Address
� .1
Death Certificate Filed Distn N� Register Number
>< City,Town or Village
Cemetery
Date
t
or Crematory ry
❑Burial
1
E449<emation Address
�.J
Date ; Place Removed
+C? ❑ Removal and/or Held
and/or Hold ::......::::::::::::::::::::::::::::::::.::::::......:::::::.....:......:::::::::::::::.........
::
Address
Q:.....::::.:::::::::...:::::::::.::.......... ::::::::.:::::::::::::......:::::::. ........... ......::::.:....:.:.....:.........................
....................................
........................
..........
Date Point of
❑Transportation by' ' Shipment
Common Carrier ...................................................................................................
...............................................
Destination
.........................................::::.Date::::,:..................................................... ...............................................................
❑ Disinterment Cemetery Address
:.:::.......................................... >:::Date:::::..................... ............ .......................................................................
..............
❑ Reinterment Cemetery Address
Permit Issued to ; Registration Number
:...
Name of Funeral Firm / G a
Address
............. ........................................... ....................
..::.:............:::: :::..:........................................::.::....................
CJ....�9......... ..
Name of Funeral Firm Making Disposition or to Who
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
" Date Issued U Registrar of Vital Statistics 3,1-4 L
(signature)
District Number Place ( � i� 'sY,
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition -'� Place of Disposition s/t��i��° ! �/l�R�/C `�/
<; (address)
w
(section) (lot number) (grave number)
;gip: T
p; Name of Sexton or Person in Charge of Pr mises l
Z (please print)W.
Signatured---XAJTitle � �1��/
DOH-1555(9/86)p 1 of 2(formerly VS-61)