Good, Ann S NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
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Date of Death : Age If Veteran of U.S.Armed Forces,
lj7� � War o..Dates
h� F .. ......:.:..:v:.:........ . ......:.
Z I e of Death Hospital Institution or
E Town or Village::t .........................5 ::. .....:.:_: .:Street Address �. -'.J.....ti�/L ... ff 1 _ ...
4,....::.: �' �... ..?. ............................
G Manner of Death Undetermined Pending
�latural Cause Accident Homicide Suicide
Circumstances Investigation
. .... ......
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W. Medical Certifier Name Title
44 ..........C, �1 his .. . ...... ..........,�►?.:rJ.: .... ...
Address
Deal Certificate Filed District Number Register Number
own or Village Gc,�-�� iqu-s
Date Cemetery or CrematoryEl Burial �J/„�G'r �� C%'- "-+'.....:.... ............ ....... ....... .........
....
EjCremation Address
Z' Date Place Removed
O Removal and/or Held
1- and/or Hold ......... ............-...: : .... ._.... ::::: : . . .-...... ............... ...... ..:... .........
Address
N
. ........ . _..... ... _....... .:.:.. _..... . -::...... ........::.
n. Date Point of
cn Transportation by Shipment
pCommon Carrier ; ...... _ ...................... ..... ...... .:::.::.... _...... . -............. --.... ........
Destination
.... ......... .... . ..........
Disinterment Date Cemetery Address
.. ... .: :::. _. ...:.::::::
El Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Firm c.G G�-}` l� U /
Address
L.!.. :::.: ......� �..::,:LtJ�G .ar.- ...... ......... ......
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
......................::...:..:.:.............:.. ..................................................... .... ....::
i Address
W.
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Permission is hereby granted to dispose of the hu n r ai %de cr' d above as indicated.
Date Issued l� Registrar of Vital Statisti
(signature)
District Number Place
lie
I certify that the remains of the decedent identified above were disposed of ' accordance with this permit on:
W Date of Disposition ` -7/ Place of Disposition P/ n � C� !.[/ C. IL him #7fJ A �I V 0-7
(address)
ul
;N (section) (lot number) (grave number)
fr'
aName of Sexton or Person in Charge of Premises f C A e-1 �,a a�e
Z '�., , o (please print) Q
W Signature �J�l L - - Title CrA,02 v ' S sf
DOH-1555 (10/89) p. 1 of 2 VS-61