Gapski, Baby Girl NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Biostatistics-Vital Records Section
Name First Middle Last Sex
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Date of Death A e If Veteran of U.S.Armed'Forces,
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War or Dates
Place of Death Hospital, Institution or
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City,cTewe-efillage— Street Address
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..,,.. Cause of Death -
Medical Certifier Name T`....................
Address (�
Death::::::
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Certificate Filed District Number Register Number
City,Tewn-orttrthaJe 'Q
Date CemAjery or Cremato
❑Burial I-3
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Cremation Are
Z Date Place Removed
+� ❑ Removal and/or Held
and/or Hold.. ............................................................................................................................................................................................................................
Address
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tL Date Poirit of.........................................................
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and ❑Transportation by Shipment
Common ..............................................mon Carrier
Destination
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❑ Disinterment : Cemetery Address
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❑ Reinterment Cemetery Address
Permit Issued to
/ Registration Number
Name of Funeral Firm i1
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Address ................. . ...................................................................................:..............................
:;.„.....Name.of f=u... ........:.::::...............:.:........:::.:::::::::::.......:. .....:::::.::......:......:::::::::::::..............
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Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
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Permission is hereby granted to dispose of the human re ns des ed abo as indicated.
Date Issued 7 /jAI� Registrar of Vital Statistics
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» District Number oz . Place
1 certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
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Date of Disposition Place of Disposition k4l, 4J 9AFA&7e/!�/U/�
(address)
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Y.
section lot number rave number
.01 Name of Sexton r Person in Charge of Pre ises
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W Signature (please print)Title �'�Ii�!a!(l' ��s/
DOH-1555(9/86)p 1 of 2(formerly VS-61)