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Dunbar, Charlotte NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name Fir Middle; ,A` Last Se Date of Deatfi Age If Veteran of U.S. Armed Forces, 76 War or Dates r"7w Place of Death Hospital, Institution or City, Town or Villag Street Address Manner of Death Natural Cause Accident Homicide Suicide Undetermined ❑Pending Circumstances Investigation Medical Certifier Name Title Address Death Certificate Filed J� Distric Numb� I Regist?r Number City, Town or Village 7 Date CgRiptery of�Wematory Burial Address --- ------ ���— -- ------------------ Cremation Date Place Re o ed Removal and/or Hel �• and/or Address Hold Date Point of ❑Transportation Shipment by Common Destination Carrier Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Regi©���umber Name of Funeral Home Address E Funeral Firm Making Disposition or to om are Shipped, If Other than Above .i on is her y granted to dispose of the human remains described above as indicated. Date Issued / y Registrar of Vital Statistics J (Sig District Number , / Place I certify that the remains of the decedent id ntified above were disposed of in accordance with this p it on: f- Date of Disposition �-,(S= Place of Disposition 6,46E (address) UJI . > (section) (lo nu be ) (grave number) 0 Name of Sexton r Perso n Charge of emises g (please print) c Signature Title ! /. DOH-1555 (10/89) p. 1 of 2 VS-61