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Myres, Raymond B NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Vital Records Section Name First Middle Last Sex f !...1.�t ::f �: 3 .::::..::..;.......:.......: �'. �............ t�l .�. Date of Death l Age If Veteran of U.S.Armed Fdrees, War or Dates (1,� ...: La:-.:..1.. ...:. .:L:..:.::::::. ( .... ............................................................. i ...........:.:...:.:....:.....:..........:..: Z Place of Death Hospital, Institution or W City,Town or Village Street Address Manner of Death Natural Cause Accident Homicide ❑ Suicide Undetermined � Pending Circumstances Investigation ....................................................,:.:..:::....:.....::.::...:.:::..:. ... W Medical Certifier Name Title r f-..�. ��......... 1' © .... .: ....... ....:.................Address..,. ..-- Z7� ....:.. . .::.:.Y.. ..:� .. � � .. r r��� .:::..:........:................................... :�..�f...r... ..... ......: :.:.. .....: .....: Death Certificate File l District Number Register Number City,Town or Village d:S4-C-6 Jiil f c 37, Date Cemetery or Crematory El BurialI ') .. ..-�'f`�1.. +u� Cremation Address e�,� n �/ .................. .. :_. .... .............................................. Z>. Date Place Removed OI', El Removal and/or Held H' and/or Hold ................:..: ...:..... ...... ::::. .................. .. ............... _ ::..... ..... Address d7( 0......... ..:.:..............................................::................. ........ ..::::_ .... . ......_.... IL Date Point of N< ❑Transportation by: Shipment p l Common Carrier ......................................... ......... Destination ...............:.......................................... . .:..... ❑ Disinterment Date Cemetery Address . :::. ..._ ..... ❑ Reinterment Date Cmetery Address Permit Issued to ` Registration Number Name of Funeral Firm 1 ����}rl �5 l i :::. :.: ..: ..cd::f._ . .... Address 1 . . ....... .. .... ..... ..... .. . .............. Name of Funeral Firm�Mak'ing Di posi' nor to Whom Remains are Shipped, If Other than Above ............:.........::...................................................:...:....... .:.:........:..:.:........ .:.... .. ........:.:..:. .......::: #�C.. Address ...... _ ...... is Permission is hereby granted to dispose of the hiAn nyie ins desc ed\rve as Gated. Date Issued Registrar of Vital Statistic (signature District Number Place `rD 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 W 2 (address) w N (section) (lot number) rave number) c p Name of Sexton 0.y2flrson in Ch ge of Premise b i i Z (please print) 11J, Signature L Title DOH-1555 (10/89) p. 1 of 2 VS-61