Davies, William H NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Biostatistics - Vital Records Section
Name First(r � , , Middle Last S
Jam, .>:Q m ..... �I_.,..:.:. S_ ex
Date of Death A�e if Veteran of U.S.Armed Forces, '
9
t.. ` ,.. 3... War or Dates
Place of Ueath
Hospital, Inst,tutio or
City Town or Village Street Address
L : . ....... ..... ................................. AJ744/#
Cause of Death
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edical Certifier Nam Title
Address ` w V ....:..... 0 ...:...:..::.:..... ..
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Death Certificate Ftl..: _ eg
District Number .:..:...:..........:...:,......::.:.. .
City,Town or Villa4L�
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❑Burial Date i Cem tery or Crematory I
/ _
aCremation
Address :.:..:.:..:.:.::
z; Date Place Removed
0: ❑ Removal and/or Held
H and/or Hold _ . ....:::.
. Address..... _:::.::.: .... _:..:,:..
Font of
.:::.......:::::......
:...:.:..:..:.:.:.
rail ❑Transportation by Date Shipment
p Common Carrier -
:: Destination
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:
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Date Cemetery Address
t;
❑ Disinterment e.
::...:::....::.
❑ Reinterment Date...:..:...:...:.. ..���... . Cemetery Address..
Permit Issued to
Name of Funeral Firm , l ,� .�.m
RegistrationNumber
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Address (�
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Name of Funeral Firm Making Disposition or io 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 rem ins described ab 1 as Indicated.
<; Date Issued ��—`��
Registrar of Vital Statistics It
(sgnatur
District Number Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W` Date of Disposition9� Place of Disposition //x.�� l/jl� ��' ii�/ 1(1
(address)
W.
(section) (lot number) (grave number)
p Name of Sexton o Person in urge of Premis s e'•
Z:
w (Please print)
Signature Title
DON- 1555(9/86)p 1 of 2(formerly VS-61)