White, Gilbert NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name Fir Middle t Se
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Dat f Death Age iIf Veteran of U.S.Armed Forces
War or Dates
Place aeath j Hospital Institutio�oc t
Cit Town or Villa e �� Street Address („
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Manner of Death Natural Cause Accident ❑ Homicide 0 Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
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Medical Certifier Name`` Title
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Address
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Death Certificate Filed � District Number Register Number
ity,Town or Village OnletiS NA1(5 ���� / Cry
Dat tery or Crematory
❑Burial C M/ Tp!L
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Cremation A res
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Z :::::::: Date Place Removed
OI', Removal and/or Held
H> and/or Hold :::...:.......:..:.:.......... ......................................... .......—...I...............-......, ...:::::.
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Address
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ti Date Point of
1ni ❑Transportation by': Shipment
p' Common Carrier .......... .. ........ ...........
Destination
Disinterment
Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration
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Name of Funeral Firm. '�x. .. '. I� E�.)2 ..i.:uN(?I , �'+'
Address
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Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
.......................................
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Address
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Permission is hereby granted to dispose of the human emains described above
abovvepas indicated.
Date Issued Registrar of Vital Statistics__ 2�Ok �iti`
` (signature)
District Number f z L9 Place / Fit, S
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
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W Date of Disposition ?`�` Place of Disposition �0� 5' ��i�/�'//7
(address)
t�.
Cf) (section) (lot number) (grave number)
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>p'; Name of Sexton or erson in arge of Premises Ko '0,,�ZfA)
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W' Signature Title /� t
DOH-1555 (10/89) p. 1 of 2 VS-61