Erickson, Frederick NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name Fir Middle Last Sex
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Date of Death Age If Veteran of U.S.Armed Forces,
O 9.3 /S War or Dates
ZPlace of Death , / Hospital Institution nor
City own o..Village �7'O.f'/CDiI/ Street Address J`'i�firSE f�i G G /r0/9.0 SLJiQ,q,CJ
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uManner of Death ❑ Natural Cause Accident ®Homicide ❑ Suicide ❑ Undetermined Pending
Circumstances Investigation
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W. Medical Certi Name Title
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Address
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Death Certificate Filed District Number Regis er Number
City.Town or Village
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Date Cemetery or Crematory
❑Burialn0.
'
Cremation Address
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Z Date lace Removed
O' ❑ Removal a and/or Held
H and/or Hold .::..:.......:::.:........ .................. ......: _ .: ::::. ..:_:::::
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Address
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a' Date Point of
:cn []Transportation by: Shipment
p< Common Carrier ..:.:... ... ....... .. - .. . ............... _ :.
Destination
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❑ Disinterment Date Cemete Address
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❑ Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Firm &A.e7-o,rl .may)cD,F,ema7l
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Address
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-: Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, IfOther than Above
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Address
i
Permission is hereby granted to dispose of the hun remains describ d above as indicated.
Date Issued - T - 90� Registrar of Vital Statistics GHQ
(signature)
District Number Place ':�N
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: /
Z; Date of DisLLJposition Place of Disposition /�/�� ��iC�/1✓I�/O�/'!�
(address)
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N' (section) (lot number) (grave number)
g T�l�i�/l�� 1� 24 f IF/9 4J Sexton
p, Name of Se Person in C ar a of Premises
Z (please print)
W Signature Title L - ,L /� �Y
DOH-1555 (10/89) p. 1 of 2 VS-61