Mattison, Arthur NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
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Date of Death Age If Veteran of U.S. Armed Forces,
War or Dates ��6A
Place of Death Hospital Institution or
<Cit Town or Village 3 Street Address G jz 14
.:_... ..
i Manner of Death 1-1/Natural Cause Accident El Homicide El Suicide El UndeterminedPending
14 W Circumstances Investigation
W.
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Medical Certifier Name Title
0'
Address
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Death Certificate Filed District Number Register Number
it Town or Village 36
a
Date Cemetery or Crematory
❑Burial q
.� ..� . ...
_.......
[.,Cremation Address
Z Date Place Removed
O ❑ Removal and/or Held
H and/or Hold ::..... ...:: .:... .: .::: . .:
Address
N
0.........
CL Date Point of
Ln ❑Transportation by Shipment
p' Common Carrier ..:.:::::.. ::.:....
Destination
❑ Disinterment
Date Cemetery Address
❑ Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Firm try-✓/19�y C2Fw9�Jca-J ,tsso C�q 7-6 S (;�
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Address
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Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
............................:............................. ......... ..........
Address
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al
Permission is hereby granted to dispose of the ma emains described ove as indicated.
» Date Issued /I -/o—S%f Registrar of Vital Statistics �1�-C�.
(signature)
District Number SGO Placey_ '✓tl-
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Ir
z Date of Disposition - Place of Disposition
W (address)
W
rn (section) (lot number) (grave number)
1X (�®
O
p Name of Sexto or Person in Charge of Premi s
Z> (please print) Ss,`
w Signature Title !r
DOH-1555 (10/89) p. 1 of 2 VS-61