Moore, George D NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
i` .. . .1. ........ m�o . ....
Dat a th n Age If Veteran of U.S. Armed Forces
3 / 7 9 War or Dates l/
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WPlace of Death Hospital Institution or � � jj /
City, ow r Village �� �� � �� Street Address , 7z� .- 7q- t�
G Manner of Death Natural Cause Accident Homicide Suicide Undetermined Pending
❑ Circumstances Investigation
U _ ............... _ .... . ... .......
Medical Certrfier Name �j � � Title ,
o. .:::........:::.: :... .....:.............. �' :. ' ... ...... / J/9.�4' ..... ........: .......
Address
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Deat ificatVV
e Filed District Number . Reg ster N tuber
City, own r Village
Date 6 etery or emato
❑
Burial
� a- .:. t.9 ..1... . . . .
remation Address
....: � I ... ............ - .... .... _.........
Z : bate Place Removed
O ❑ Removal and/or Held
F- and/or Hold ..Address
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Address
en
0........................ .. ........_ .......
a Date Point of
N ❑Transportation by Shipment
p Common Carrier .......:.
Destination
......... .. .........ry
❑ Disinterment
Date Cemetery Address
.......
❑ Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Firm
g ........
Address
e
......
Name of Funeral Firm Making Disposition or to Whom
g; Remains are Shipped, If Other than Above
..
Address
a>
Permission is hereby granted to dispose of the human rema'ns describ a ove as indicated.
Date Issued u G': �/ Registrar of Vital Statistics
(signature)
District Number y Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
p� n r
Z Date of Disposition D�� Place of Disposition /�,� Z2, 11
2 (address)
W''
Cl) (section) (lot number) (grave number)
c
p Name of Sexton r Person i harge of Pre 'ses �fm �Z�� d
z (please print) y-
W Signature Title
DOH-1555 (10/89) p. 1 of 2 VS-61