Curran, Susan NEWYORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Biostatistics -Vital Records Section
Name First Middle Last Sex
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.................................... ........
212:. .... .... ..
Date of Death Age If Veteran of U.S.Armed Forces
War or Dates
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:Z Place of Death Hospital, Institution or
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': City,Town or Village l
Street Address Y, g
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DCause of Death > �7 ..�7....... ......................y� .................................................
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C . Medical Certifier �J`I�a�'e _ Title..........................................................................................................
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Death Certificate Filed District Number . Registe er b
City,Town or Village 7yy
Date Cemetery or
or Crematory
Burial :....................�� .. 3 n. ......... ................ / .:' ... U.:...F 4 ...: . / f?T ........................
®Cremation
Address
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z, Date Place Removed
Q: ❑ Removal and/or Held
H. and/or Hold ...............::.:......: ..... ...::..:.: ....:::.............................:............ ........
Address
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G. Dat.e Point of..
y; ❑Transportation by.. Shipment
Common Carrier ....................................................................................................................................................................................................
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Destination
Dat .......::--C:........ .te...ry..Ad dres..............s....::::.. - .......................................................................
❑ Disinterment
e eme..
....................... ..:................... ...: ...............
❑ Reinterment
Date Cemetery Address........
Permit Issued to Registration Number
Name of Funeral Firm �,` --
t.: '........./.... 1................. . 1�'�.................... ...................:.....:. :....... ...
Address
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Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
is is
Permission is hereby )granted to dispose of the dd hum remains descr bed above as indicated.
Date Issued 1�' � . f%U Registrar of Vital Statistic
s ature)
District Number Place
certify that the remains of the decedent identified above were posed of i accordance with this permit on:
w' Date of Disposition 3a �� Place of Disposition /l�,t� !/ /�� �!�i llm O/P/C�/
(address)
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Cc C (section) (lot number) (grave number)
nName of Secton or Person in Charge of Pr mises ,E,d�/9/s'Q /,/)9 'cl
Z (Please print) d
W' Signature Title �/��> /D
DOH- 1555 (9/86)p 1 of 2(formerly VS-61)