Robinson, Harry ri
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,
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4 Place of Death Hospital Institution or
Cit Town or Village sS'�,-a`�Y 2 N Street Address S.9e.5 V6::-
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W Manner of Death ® Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
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..Uj Medical Certifier Name Title
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Death Certificate Filed District umber Register Number
City Town or Village
Date Cemetery or Crematory
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Address .:...:.......
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Z Date Place Removed
Olj ❑ Removal and/or Held
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Address
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QL Date Point of
tni []Transportation by Shipment
p' Common Carrier p
Destination
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❑ Disinterment Date Cemetery Address
ate D Cemetery Address
El Reinterment
Permit Issued to Registration Number
Name of Funeral Firm / ee w 'sv �/r.
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Address
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44 Name of Funeral Firm Making Disposition or to 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�'s des above `as indicated.
Date Issued Registrar of Vital Statistic''
signature)
_! District Number Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
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LU Date of Disposition Place of Disposition 110%n/ e-(2 i C461 ' 1& ( ► 0 in
2 (address)
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In (section) (lot number) (grave number)
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p Name of Sexton or Person in Charge of Premises i c
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W Signature 1 Title p 1/9i 2 I/'/�(L4�/� i4 T k5c,
DOH-1555 (10/89) p. 1 of 2 VS-61