Ploof, Julia P NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
X
Name First Middle Last Sex
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Date of Death Age If Veteran ra"n,....6 f U.S.L m e:�?-Forces� ,
War or Dates
PI 77
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ce of Death Hospital, Institution or
Street Address Wj City own or Village
I Y, �_S' - --L ct-
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W 'X ccident D Homicide El Suicide
O Manner of Death E] Undeterm P ding
Natural Cause El
...... Circumstances Investigation
V,
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.dj Medical Certifier Name Title
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Address
A,)....... .................................. . .....................................
........................... ........ District .......
Death Certificate Filed District Number q Register Number
Town or Villag e
Date Cemetery or Crematory
❑ (4
Burial V Q- C- 'k
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Cremation Address
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z Date 04!4�m 0-Pe
2 El Removal and/or Held
and/or Hold . ........... . ......................... ...... . . ........ .. ....... .
Address ....... . ........................ .. ..................... ................. ........
Fn
0...............-1.1.......... ....................... .............................................---...........................................................................................
Date Point of
cn E]Transportation by
Shipment
CommonCarrier ........................................... ..................................................................................
Destination
a
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El ............
Disinterment bate ........................... Cemetery..... A...d...d...r.e...s..s.......................................................................................................................
..........I ...... ......... . .... ........................................................................................................... ......-..... ...................................................................................................................................
Reinterment Date Cemetery Address
El
Permit Issued to Registration Number
L
Name of Funeral Firm
0
.................... . .............. ................................... ................. ...................................................... ............................................. ........k.7.......
Address
....................... ...............-.... .....7--.5kc r, Aklic r -A 4-�
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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 7 hu ma s describ ve as indicated.
7" prgbf
Date Issued Registrar of Vital Statistic s 7
--Kij-nKreT—/ L-1
District Number Place �t4j �O 1
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
z Date of Disposition 'cep-IrA
31 C1,7 Place of Disposition
(address)
LLJ
Cn
M (section) (lot number) (grave number)
0
0 Name of Sexton o Person in C arge of Premi5es A&Y 7—
z I/ (please print)
LU Signature Title 4� - 77
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DOH-1 555 (10/89) p. 1 of 2 VS-61