Harvey, William NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Biostatistics-Vital Records Section
Name First M' le
/ Sex
Date of Death Age / ff Veteran of U.S.Armed Forces,
War or Dates
Place o eath Hospital, Institution or
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ow ill Vi or a9 e L Q�t
Street Addressj,
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ause of
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Medical C i ier Name ! T'I
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Death Certificate Filed j '
District Nu- Register Number
City,Town or Village C 1 '/j J
Date metery or Cremat
ElBurial ::::::::::::::::::.:::::: ;'. U:::::.....::: 17 ..v..... ::::::::::::::::::::,::.
Cremation Mress
L
Z Date f Place Removed
�Qjl ❑ Removal and/or Held
and/or Hold ......:
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:. Address
0 : Date Point Of.................................................................................
❑Transportation by Shipment
Common ..........................................................................................................................
0 Carrier
Destination
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El Disinterment
Date Cemetery Address
..........:......::....:.::...........::..:::::::::::::... .
❑ Reinterment
Date Cemetery Address
Permit Issued to Registration Num r
Name o..Funeral Firm
I
� 2
-/
o
;> Address
7
Name of Funeral Firm Making Disposition or to Whom t
—Z:: Remains are Shipped, If Other than Above 6
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Address
.: ............................................................................................................................................................................. . .......
Permission Is hereby granted to dispose of the hu remains scrib d above a Indfcated.
Date Issued j-4, Registrar of Vital Statistics
(signature)
District Number J Place
I certify that the remains of the decedent identified above were dispcWed of in accordance with this permit on:
H
w Date of Disposition Place of Disposition 1 p L ! Ll Q/ C_C-P d') fjF Lou-
(address)
w,'.
Z (section) (lot number) (grave number)
0 g ' 1' / � Oa?-ai Name of Sexton or Person in Charge of Premises / C ��r'
Z ,I /(please print)
W' Signature �Ll / � Title e��
DOH- 1555 (9/86)p 1 of 2(formerly VS-61)