Young, John ,5- 3r
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Biostatistics -Vital Records Section
Name Fir Middle t Sex
.
Date of Death Age If Veteran f IJ.S A ed Forces,
�� ff 19 q f W p War or Dates /lld
.. ...:::.. .......-..... .............
..
Z: Place Bath Hospital Institution or
City, own rVillage ®a/tJ Street Address MA>4
ti S�r�� t
...
........ ..............
Cause of Death
Medical Certifier Name Title
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Address:::::........................................................................................................................................................................................................
p :::. .................................................................. .. .................................................
eath ificate Filed District NumberG Register Number
City,Town Village
Date /p Cemetery or Crematory
❑Burial ��. /d:.1../.: Q
/.fie view.:..E'Y ...TO- ...:........
�remation Address �'j)
...(fF�jUSrJur /U r
................
Z Date Place Removed
0; ❑ Removal and/or Held
1- and/or Hold . .......
Address
0::. ..........:P.......... ........:....:...... ....................... ..................
0. Date ; Point of... ......:............................... .:.: ......................:....
U) Transportation by..
Shipment
II Common Carrier
Destination
.. .............................. ............................... ............ .................................................................................................
El Disinterment Date Cemetery Address
........................... ......................:::.:.
❑ Reinterment
Date Cemetery Address......................:....:.::.:...:.......................:.:.:...........:..........................
Permit Issued to ! / Registration Number
Name of Funeral Firm C�A f!y �vA)t,Al / lofl QQ�S '�
t...... [ F�....:.: ......:. .:.........................:...
Address
rwoJ..........1�..�.�-.... .. . ° '^�-�'' / .. ......................... . . . ........ ...:............. .
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
.: ..........................:.. .. _.......... .......:.:: ....-.. ................... . ..................... ......:. __.:..:......:.:.........
Address
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Permission Is ereb granted to dispose of the dead human remains described above as 'ndicated.
Date Issued // Registrar of Vital Statisti
1
(sign e)
i
District Number Place
1 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 P►FAI-e flf'% �W-1 C r e fyM r
(address)
w
(section) (lot number) �L (grave number)
GName of Secton or Person in Charge of Premises
Z (Please print)
W Signature Title
DOH-1555(9/86)p 1 of 2(formerly VS-61)