Gaynair, Alton NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First Middle Last S
CK 06L r
1 --............................................... ................................................................ .................................................................... .................
Date,of Death Age If Veteran of U.S.Armed Forces,
...... War or Dates
+— & .................. ... ...... ........
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: Hospital, Institution or Place' ''6&b eaffi..............
z
:.Wl City,Town or Village 6% Street Address
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:10 Manner of Death E] Pending
Zi-Manner-...................
M A.
i.. Natural Cause El Accident El Homicide El Suicide 0 Circumstances Investigation
.................................... .....................................................................................................I.I.I.I...........,.....�.I...........................,.I....................................... ....................................
Medical Certifier Name Title
M4 0 Y�
.............I........ ..... ......................................................................................................................................................................................... ....... ................ ..............
Address
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Death Certificate Filed -District...Nu-m-be-r...........................
Register Number
X.
City,Town or Village (?Al S 4US SUM
Date Cemetery or Cremat.Rry
❑
.......
Burial .. A..v
. ................................................... ..... ............................ . .
' '--'
ED/Cremation : Address:
.I ..................
zDate ...v......... ......................................................................... ...........................................t4... ....
........................ ......
Place Remoed
2 E] Removal
and/or Held
and/or Hold ............................................................. . ...... .... . .. ............
Address
0.............. ......................................... ........................................................... ............................. ............-
OL Date Point of
co: E]Transportation by:
Shipment
FSCommon Carrier .............-................................................................ ..........-...............................................--.................- ..............
Destination
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0 Disinterment Date Cemetery Address
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................... .. ........... .........
... ................ . ........... .......... ........ . .......-
E Reinterment Date Cemetery Address
Registration Number
Permit Issued to
XXX
Name of Funeral Firm �v ku lr(4........... ......
................... ......................... .................................................................. ................... . .........................
Address
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Name of Funeral Firm Making Disposition or to Whom
:21 Remains are
e Shipped, If Other than Above
........................................................................................................... ..................-........................................
ii Address
4..
a
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Permission is he py granted to dispose of the hu mains described above indicated.
Date Issued Registrar of Vital Statistics
r.
Place
(signature)
District Number 24/ZZ
-Z
I certify that the remains of the decedent,-f dentified above were disposed of in accord,ence with this permit on:
Z 5 —/ 0
LU Date of Disposition _7cW- Place of Disposition Z�71'
(address)
Ljj
0) (section) (lot number) (grave number)
cc
0
a Name of Sexton Person injhar f Premi s
z (please print)
LU,
Signature Title
.......... ................ ........
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DOH-1555 (10/89) p. 1 of 2 VS-61