Falkambury, Frank 1--� / & 1
NEW YORK STATE DEPARTMENT OF HEALTH BUCIaI - Transit Permit
Bureau of Biostatistics - Vital Records Section
Naine First
Last
Date of Death . . .............
e
Age If Veteran of U.S.A m d orce ,
...................... . d� War or Dates
Place Bath _ ..:....:.................... .............
.:.
Hospital, Institutio nor
lJl _City:.. °:..: o Village I '
G C✓��rk✓ Street Address ` ✓hl_
G1 Cau Bath ........ .:.....: ...:........:........
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W`
Medical Certifier Name ..... . .....
Title
Wit.. ,��,., t
Address .. .::. ............,.........:... .....:...-
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Death Certificate Fled " ' �!........
istnct Number
.: :.:.,........ ..:.
Register um r ..v.--h•��
City own r Village ���c ✓ ��S
Date Cemetery
El Burial
_
C ery rematory
remation
Address ..::... `......... . ........::.,. .!'►'�G�-c�rc !ter1
.... ;...
z :: Date ::...:..:.. .:...:..,.::.,..::....:..:..
L:�)Y-b
0 ❑ Removal ae Removed
H and/or Hold d/or Held
Address
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N
0..
-..:
Date ........................... ......... ........ ..... ..................__
o. _,......:.......,
v) ❑Transportation by Point of
p Common Carrier ;.......:...::.:::..:...:..::..::::.:.:........:.....:..:. Shipment
.....:.........................:. .................... .........
Destination
# Date -.:.:....,- .. .....:._ ......... ...::... .::.... ................:.:.......:
❑ Disinterment Cemetery Address
.:..........
_:::.:: ....:..:
:.:Date ..:. _.........:.....::::.::...:::::.::::.::::....::.. :::.:.....::..,.::::..:,.
❑ Reinterment rY x.r.
'�-Cemete Address
Permit Issued to : Registration Number
Name of Funeral Firm
Address } 4�84 ........:..,..:.. :.:., .. ...:::.,..::..:.r,...: ....
Name of Funeral Firm Makin Dis ::...:::::.:....:..:.,.:.,:....,.....,...,
g position or to Whom
Remains are Shipped, If Other than Above
...........,:.....:..
,........Address
W:
....... _ ......._.....::..........::.:....::::::::::..:.::.:..::.:::...::::.,. :...:....,.::::., ...
Permission Is hereby granted to dispose of the rem Ins'dq�n, abov I to .
Date Issued �'���Registrar of Vital Statist!
e)
?> District Number Place
I certify that the remains of the decedent identified above were di s se of in accordance with this rmit n:
z Date of Disposition Place of Disposition / /
2 (address)
uu
in
(section) (lot number) (grave number)
0
0, Name of Sexton or Person in Charge of Premises ,
W Signature (PWase print)
g 2in 1'tolelUm 1
Title �P
DOH - 1555 (9/86)p 1 of 2(formerly VS-61)