Smead, Catherine NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First Mtddle Last
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Date of Death .Age : If Veteran of U.S.Armed Forces
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/� War or Dates f /v
Z Place of ow rDeath Hospital Institution or
i},{ City Town or Village Street Address �� d
ip Manner of Death.... ....:..:............ ....... ... :: ......... ....... . Undetermined ending
W ® Natural Cause Accident ❑Homicide ❑ Suicide
Circumstances Investigation
Medical Certifier Name T�
p � .e�C v �7
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Address
e9 fit'
Distr t Numb r R i er�N6'�6eDeath Certificate Filed
City,Town or Village
Date em tery or C/re7fatory
❑Burial .: ..... \ l LC ..(/-GIG1
. ... .
remation Address
Z Date Place Removed
O', [] Removal and/or Held
F- and/or Hold :::::::: .:: ._..... .........__ ....
Address
N
O.............. _ . ........
Date Point of
cn []Transportation by:: Shipment
p' Common Carrier ..... ::....... ::::::,: _ ..:::.:.. ... ..................................... ......:::: :..... ........::::
Destination
El Disinterment
Date Cemetery Address
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❑ Reinterment
Date Cemetery Address
Permit Issued to Ret� tau r
Name of Funeral Firm /
Address
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.....:......... .:..: .::..
Name of Funeral Firm Making Disposition or to Whom
g Remains are Shipped, If Other than Above
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ui
Address
a
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Permission is h reb granted to dispose of the hum ��airy$ scri ed b &9ind icate/mod.
Date Issued / Registrar of V; I Statistics
(s' n re)
i
District Number Place`
certify that the remains of the decedent identified a ve were disposed of in accordance with this permit on:
Z Date of Disposition position yJ��/yc� V/,4�� l�. i /9/� /L,/►'/
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W Place of Disposition
(address)
w
cn (section) (lot number) (grave number)
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p Name of Sexton or Person in arg a of Premi es
Z' (please print)
LLI Signature Title
DOH-1555 (10/89) p. 1 of 2 VS-61