Deich, Erna NEWYORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Biostatistics -Vital Records Section
Sax
Name Firs: NW& Iasi
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::;.::: Date of Death Age If Veteran of U.S. Armed F roes,
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War or Dates
Z Place eath Hospital, Institution•or••
City own r Village e :' Strest Address
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it7€ Cause Bath
' .•Medical Certifier M Name _......Title._..... .......
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Deat ficate Filed D+s.{ t Number 1 Reg+s' Number
City Town` Village
Date metery or Crematory
❑Burial
Cremation
Z
Date '�•••--••- Place Removed
O El nernoval and/or Hold
and/or Hold`.......•-..........:................................................................;........................................................:..........,...........-... ..,,,..,:.,...:..-._...:.,:.:...,.:.....�.M.:...:...,. ..
Address
:
G Date Point of
Ln Ej Transportation by Shipment
Common Carrier
s Destination
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Disinterment
Date Cametery Address
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❑ Date Cemetery Address
Reinterment L
Permit.,lssued to Re
gistration Number
Name of Funeral Firm
Address
j Name cf Funeral F'um Making Disposition or to Whom}
Remains are Shipped, if Other than Above
:....Address.».....:,...,,�...............:......::..M.,.,.:........w....."..........,_,.......
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Permisstort s hereby ranted to .dispose of the hu n aural s des 6e ab ve as indicated.
Date Issued �� Registrar of Vital Statistics
s' -'ur
District Number Place
I certify that the remains of the decadent identified above re disposed of in ccordance with this permit on:
Z� Date of Disposition Place of Disposition re,MaTo CY �•
(address)
t11
(seclicn) (lot number) (grave number) '
a. Name of Saxton or Person in�Coti�arge of Premises
Z �� ' (Fieasa r irr)
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signature
Titte creme
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CCI•i- 1555 (°Ifioi p t of 2(fcrmerty VS-o"t)