Granger, Leonora NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
eo .. .. .. .................�- ......... .. . ....
Date of Death A If Vetera�i f U S.Armed Forces,
War or Dates
~ Place of--eath Hospital,ital, Institution or `
Z
l!1 City,Town or Village Street Address Z"ni"
...............Manner of Death I'Q( Natural Cause Homicide Suicide Undeter fined Pending
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W � � � Circumstances Investigation
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Medical Certrfier Name Title
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::......Address
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Death Certificate Filed �e District Number , : Register Number
City,Town or Village c�-
Date etery or Cr matory
❑Burial
Cremation Address
/PIN'
Z Date Place Remyvd�............... ::::::::::::..::
O, ❑ Removal and/or Held
i- and/or Hold ::._:::. :............:::.................-1",.::::::::...........w—....:::::::..:..:..:.::::._::::.:,::..:::::::::::::::::.:::::::........................................
Address
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a Date Point of
L ❑Transportation by : Shipment
p' Common Carrier ......... ..............
Destination
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❑ Disinterment Date Cemetery Address
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❑ Reinterment Dale Cemetery Address
Permit Issued to Registration umber
Re jion N
Name of Funeral FirmQ i y.... J�-n .:. .::......:..:.:. ":.".'.;.'^......... Q.�.. tl: ...: ::...
Address C
F; Name of Funeral Firm Making Dispositio to Whom
g Remains are Shipped, If Other than Above
111
Address
a .............
:... ......... ............................................... .
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 1 1 Registrar of Vital Statistics
(s' aatture)
District Number �C�— Place N-Y\
I certify that the remains of the decedent identified above were disposed of in accordance with is permit on:
Z Date of Disposition 1J f[` Place of Disposition / /r��y/Rv GW���1�J�7/) /�,r
ut (address)
w
N (section) (lot number) (grave number)
Op Name of Sexton or Person in Charge of Premises ��&j��_D 1 &
Z lease print) n ` y'
ul Signature s Title �M4zm A 7d C Y
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DOH-1555 (10/89) p. 1 of 2 VS-61