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Harris,William NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Vital Records Section Name Fi st Middl �� Last S �5 M P h Age Dat of D at If Veteran of U.S. me�d�o,�ces, War or Dates ff�S �U Hospital, Institutio o Place of Death � �� Street Address City, Town or Village Undetermined Pending Manner of Death Natural Cause Accident Homicide oSuicide Circumstances Investigation re, edical Certifier Name Address Register Number Distric m r LI Death Certificate Filed City, Town or Village t© N Dai Ce tery�r Cre ay ❑Burial Address U (� U 151�os Cremation " Place Removed Date and/or Held 0❑Removal and/or Address F— Hold 0 Date Point of N❑Transportation Shipment Q by Common Destination Carrier Cemetery Address Disinterment Date Date Cemetery Address Reinterment egistrati r Permit Issued to �,7 Name of Funeral Home�� / Address f Na me of Fueral Firm M ing Disposition or to Whom Remains are Shipped, If Other than Above Address e Permission is h eby r o ted of dispose of the human remains de ribed above sinnt . Date Issued 6 Registrar of Vital Statistics (signature - G Lo District Number Place the remains of the decedent identified above were disposed of in accordance with this permit on: I certify that ionAl Place of Disposit M ' g Date of Disposition � j ' (address) N (section) (lot num er (grave number) 0 Name of Sexton or Person in Charge of Premises (please print) t) r gC Title Signature (over) DOW1555 (9/98)