Jasper, Amber NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Middle Last Ig
NarnFirst GAge If Veteran ofUS. Armed Forces,
Date of Death - Waror Dates
HPlace Death �; Street AddressCity, ow or Village Undetermine Pe oPeMann f Death ❑Natural Cause Accident Homicide Suicide Circumstances Inv
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Medical Certifier Name n ' t ]
Address t� "Y1(, !V
Di i er egis er Number
Death tificate Filed \ ; �`�
Cit own r Village W etery or remat ry
Date 1 )(.a G�jVAL IN m a'
❑Burial t ll l/
Address ��
Cremation '
Date Place Removed
z Removal and/or Held
❑and/or Address
I' Hold
Date Point of
0 Shipment
NQ Transportation
by Common Destination
Carrier Cemetery Address
Disinterment
Date
Date Cemetery Address
Reinterment
Reyistratitiionn umber
Permit Issued to LA
Y�l C
Name of Funeral Home MC,Or1112 IA
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<> Address Z.e6
Name of Funeral Firm Making Disposition ol to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
�3)q�1 Registrar of Vital Statistics z GL
[ Date Issued ! g (signature)
i District Number 5
Place 12�33
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
y
Z Date of Disposition Place of Disposition
W. (address)
tWl� ction (I t numbe ) (grave number)
r� (section) �T1Q Name of Sexto or Person in Charge of Premises
Z Title On
W Signature
VS-61
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