Fitzgerald, William J NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First Wdle Last Sex
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Da .te of Death Age If Veteran of U.S.Armed Forces,
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/.a e of Death Hospital Institution or
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W Manner of Death -� Natural Cause Accident ❑Homicide El Suicide Undetermined Pending
Circumstances Investigation
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Medical Certifier D/Name N/ r /Title
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Address /�..
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th Certificate Filed District Number Register Number
Cit Town or Village .3
Date Cemete or Cremat ry
❑Burial
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['Cremation Address
Z Date Place Rem ved
O,, Removal and/or Held
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Address
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CL Date Point of
N Transportation by Shipment
Ei Common Carrier ......... ....... ......:.. . ..... :.. _ :.......
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Destination
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Disinterment Date Cemetery Address
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Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Firm s [�s._.S:&j ...: -::. L��✓lr! f•../ u�.c. .......... ...
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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Address _
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Permission is hereby granted to dispose of the man r ins des ibed bove cated.
Date Issued //� - [ Registrar of Vital Statisti s Al 1
(signature) 1,7
District Number SCJ1 Place T'
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition %tl-"K^9 Place of Disposition P!n1 ,- a, ,e- 47-a u
N (address)
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Cn (section) (lot number) (grave number)
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0 Name of Sexton or Person in Charae of Premises I LIB / l ri��li
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W' Signature Title C/9- ;-m 4"rof, itr"m 1�T
DOH-1555 (10/89) p. 1 of 2 VS-61