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NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First Middle Last
Sex
Date of Death Age W)ean of U.S.Armed Forces
War or Dates
N.a...... ......
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... .. .....:. .. ..
::::::,.:::.:::....::::::::.:.::.Hos Vital, Institution or
Z
Place of Death P
'� City,Town or Village - �� Street Address� ddres
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;0 ding
Manner of Deatatural Cause Accident Homicide Suicide El
.....................................................
estigatio
Undetermined
en
Circumstances Inv n
i.cai:::.....Certrfier:,.::....:::::..:.:.:...:.:.....:..:.......::::......:::........:.::.....:::......... ....:..::.:........ Title
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Medical Name
Address
.......
Death .... ..
Certificate Filed District Number Reg'ster. .....N ber
City Town or Village f
Date Cemetery or Cremator
C urial
0 remation Address
t: I .SZ� :. � u. tS5u.4 n .........
Z : Date . Pace Removed
O Removal and/or Held
........... ........ ..- ::::..........._ .... ::::. . ..::::._ :. .::.. -:: :.:.::...............................................................
t- and/or Hold Address
0...........................:...:..::.....:::.::.......::..::.:.......:........:. .. ........ _ ,.. ....... ......... .............
p- Date Point of
'cn Ej Transportation by:: Shipment
p' Common Carrier ...:::....:... ..... .....
Destination
::.......:...........:..:........
........... ..... .... ........ ........ ........
..:.
Disinterment
Date Cemetery Address
.:.. a.......:::.........::: ........::..
Date Cemetery Address
Reinterment
Permit Issued to Registration eNumber
Name of Funeral Firm ..... ... l �.....:. .:.: .........
.�rtr . ...: ..N .... :sv� ::...:.:__ .... . .....
Address
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�- Name of Funeral Firm Making DispositionIr�to Whom
Remains are Shipped, If Other than Above
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u:
Address
n> ......... ......... ......... ..._.............. .....
.........................:....:...::......::.........:.:..:..............:...::....................
Permission is hereby granted to dispose of the human rarriai„s Lri'oed btz`r'� as indicated.
» Date Issued r. Registrar of Vital Statistics
(signature)
`
District NumberlJ Place
certify that the remains of the decedent identified above were disposed of in accordance with this permit on: ,
Z Date of Disposition 3-9� Place of Disposition �//�i�
W' (address)
w
cn (section) (lot num r) (grave number)
,�T�.s
❑' Name of Sexton r Person' Charge of remises E m � i
Z; (please print) n,c-� , / ,Q ` /�
W` Signature Title /�i� ���(V 9 //Ssl !'
DOH-1555 (10/89) p. 1 of 2 VS-61