Fish, Dorothy NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Biostatistics -Vital Records Section
Name First le Last Sex
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Date of Death : Age If Veteran of U.S.Armed Forces,
War or Dates
Place of Death ��� Hospital, Institution or
City,Town or Village /4�J n o Q Street Address r�
E3 Cause of Death
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a � r
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Medical Certifier 'Dame Title
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Address
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Death Certificate Filed District Number Register Number
>> Sityjown of Village .3
Date ii Ceepetery or Crematory
❑Burial /
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[Cremation ; Address
Date Place Removed
O ❑ Removal and/or Held
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Address
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R Date ; Point of
>N; ❑Transportation by ; Shipment
Common Carrier
Destination
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El Disinterment
Da a Cemetery Address
❑ Reinterment Date Cemetery Address
Permit Issued to Registration Number
>> Name of Funeral Firm ,� d wQ r ,�
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Address
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Name of Funeral Firm Making Disposition or to hom
" Remains are Shipped, If Other than Above
f;I Address
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Permission Is hereby granted to dispose of the human remains described above as Indicated.
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Date Issued /-01 `�— �S Registrar of Vital Statistics 22
(s' nature)
>< District Number �`5�3� Place
I certify that the remains of the decedent identified above weredisposed of in accordance with this permit on: /
wDate of Disposition Place of Disposition
(address)
w
(section) (lot number) (grave number)
a. Name of Sexton qff erson i Charge of Prerqises
W (Please PnM) aJ � /
Signature Title j!
DOH-1555(9/86)p 1 of 2(formerly VS-61)