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Zeese, Alfred NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Biostatistics-Vital Records Section Name First Middle Last Sex of Death Age© If Veteran of U.S.Armed Forces...................................................... War or Dates ,Z. Place of-Death Hospital, Institution or Cit ow r Villa9.:::::::::::::. e Street Address y' :::::::::::::::::::::::::::::::::::::::::::::::::,::::.::::::..:.................................... '_'..................................................... ......... .A: Cause of Death 4........... ll .. / :. :. ./ <:. :::.:::::: : ::::::::.:::::. :1.: .::://I� Iirt -f-.e............:.:.::.:Gi n..:::: d:7 ......... ...1 ..... ................................ .. .... .. .................. .......................................s ... ;.,_:... Medical Certifier Name Title Address ............... .. ............................................................... h j ........... ...... ..... ... .. . .................. ...... Dea . ....... t rtificate Filed District Number : Register Number City, own' r Village Date ete Cr mato ry or ry ❑Burial L�c.�rcR. remation Address e e ti /� tt.C :Z: Date Place Removed .::::::::::::: €O ❑ Removal and/or Held and/or Hold ::::::::::::.::::::::::::::::::::::::::::::::::::::::......:::::::::::::::::::,::.....::::::::::::::::::::::::::::::::::::.:::::::::::::::,....::::::::::::::::::.:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: Address 0 i> :....................................................................... ...... ............................................... DDate Point of......................................................................................�:........::::::::::::.:::..:::.::::::. v� ❑Transportation by Shipment ;p Common Carrier >::::::::.:::::::.:::::::..................................:..::::::::::::::::::::::::::::::::.:::::::. ,.::::::::::::::::::._:::::::::::::::::::::::::::::::::::::::::::::::: Destination ........................................::::::Date::::::..................................................... 1-1 DisintermentCemetery Address ........................................ ate:::::..................................................... .........................................:::: ❑ Reinterment D Cemetery Address Permit Issued to Registration Number Name of Funeral Firm .........:�-t/. .�d......... ...........e... .. u�tl Pr�4../...... i17 . ........................................................................ :::::::..::.::.......................... . ....:.X.....�...�.c� ::::.. .......::..:::./.......................:::::....:::........................................................................... Address ::::<:.........................._ L ...FIUrU.. l ....._ j...........`�-G New ./... ....... .. ... ......._�7.. _....................................... . Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, ff Other than Above pP ......................: ::::::::::,:::::::::::::::::::::::::......::::::::,::::::::::::::::::::::::::::,::::::::::::::,::::::::::::::::::::.....::::.::.::::::::................::::::: Address Q Permission is hereby granted to dispose of the human emains describ(e�'�a ve as Indicated. ?` Date Issued Registrar of Vital Statistics ,\ (signature) :» District Number Place I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: o z' Date of Disposition ILk Place of Disposition ��/ 1 w (address) W (section) (lot number) (grave number) al: Name of Sexton o erson in har a of Premis s Z' (please print) i lu Signature Title a DOH-1555(9/86)p 1 of 2(formerly VS-61)