Agard, Marvin O t �1
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First Middle t Sex
Date of Death Age etera o S Armed Forces
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4 .y W tes /9 e of Death ospi;ha
nstitution o
City own or Village Street Address
Wan' of Death atural Cause Accident Homicide uicide Undetermined Pending
Circumstances Investigation
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Medical Certifi N me Title
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` A�dp r ss
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b.... h Certificate Filed District Number egister Nut(iber
Cit Town or Village
Date Cemry rem ry
❑Burial %
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Cremation
Address
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Z Date P( a Removed
O', ❑ Removal and/or Held
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F and/or Hold .::. . ..: .:::.
Address
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IL Date Point of
tn; ❑Transportation by Shipment
p Common Carrier ........ . .. ..: :::... ...... ........
Destination
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❑ Disinterment Date Cemetery Address
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❑ Reinterment Date Cemetery Address
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Permit Issued to Registration Number
Name of Funeral Firm L . � �J ✓ � � �10//
Address ,
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Name of Funeral Firm Making Disposition or to Who
g Remains are Shipped, If Other than Above
�: Address
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Permission is hereby granted to dispose of the human a ins described above as indicated.
Date Issued Registrar of Vital Statistics BIZ
(si ature)
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District Number Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z`< Date of Disposition Place of Disposition I iV r-/f�wv� 70-2r) e-/
2, (address)
w
U) (section) (lot number) (grave number)
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pName of Sexton or erson in Charge of Premises
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`W' Signature Title r
DOH-1555 (10/89) p. 1 of 2 VS-61