Pulsifer, Anne NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First Middle Sex
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..:......
Date of Death Age If VeteAr Forces
Wr or Dates:. ........: .... ......... ..... .......... ........ ...
a
Place of Death Hospital, Institution qr,
City Town or Village Street Address
r.Z.... ..: :.. ... ..... . ........ ....... ............
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01 Manner of Death Undet fined P ding
Natural Cau A ident Homicide Suicide
11
............. :...... .. ... ..... ............:: ::....:..
Circumstances nvestigation
' .. ..........
� Medical Certifier Name � � Title i„��
:G .. _ _ ........ ......... ...... ......... .. ... .........
........................
Addres� /? .
Death Certificate Filed District Number Registe er
City,Town or Village
Date Cemetery r ematory
❑Burial
... .
Cremation Address �j / ,
I u�. .:. _,:.L: G
Z' Date Place Re oved
O' [] Removal and/or Held
F .€ and/or Hold ...................... ......... ........-: ......---... .......................... ........
Address
o..........:::.:..........................:... ..::.:.:::::::.:::.:.......:.:..........::::........................... ._.... .: ..:.: _.::..... : ... ..... .......... ...................... .
1 Date Point of
u) O Transportation by Shipment
p Common Carrier ............:..........:.................:..:........::.
Destination
........ ....... _ ......... .........
..:.:...:.........:........:.:: _
Disinterment Date Cemetery Address
El_ ....... _ ... ...... _ _ _ ....... .......
............................................................................................................................................................................................................................................................................
Reinterment Date Cemetery Address
Permit Issued to Bi�,Q Registration Number
Name of Funeral Firm �
_ ........................... ..... _. .. r.:_. .. . . ... ._ .....
Address �
......................: .. �Ahom ,.. ::.,Y... ,�
f- '�:3.................... .............
Name of Funeral Firm Making sitio
Remains are Shipped, If Other than Above
........................ . ::...... ....... ...... ... .. ....... .............
Address _
Permission is h reby granted to dispose of the human remains described above as indicated.
(4
Date Issued J Registrar of Vital Statistics v %
riature)
District Number Place
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
F- i / I
z' Date of Disposition Place of Disposition /�i/1/� /,�1�/ ���/J�f /�/(�/
W
(address)
LJ
it (section) (lot
(lot number)
(grave number)
p' Name of Se(xt�on r Person in Charge of Pre ises ��4�11 ,O M/g ;' �4/
W Signature 1' _ (please print) Title ,�/J� /Q
DOH-1555 (10/89) p. 1 of 2 VS-61