Whitney, Vivian NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Biostatistics-Vital Records Section
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Date of Death Age If Veteran of U.S. Zed Forces,
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:.fiii, Place of Deat Hospital, Institution or
City,Town or Village /�
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>E Cause of Death
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Medical Certifier Name _ Title
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Death Certificate Filed District Number ` Register Nurnber::::::..................
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City,Town or Village
Date Cemetery or Crematory
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Z Place Removed
Q ❑ Removal
and/or Held
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Address
t1 ; Date Point of .....................................................
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Common Carrier ....... .............Destination
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Disinterment Date Cemetery Address
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❑ Reinterment
:. Date Cemetery Address
Permit Issued to Registration Number
:» Name of Funeral Firm A • /'u.><�/� �j
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Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
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Permission Is hereby granted to dispose of the human++ ,,remains Ldescribed above as indicated.
Date Issued �? Registrar of Vital Statistics _l�t(1
(signature)
District Number _l. G� Place
I certify that the remains of the decedent identified above were disposed
of in accordance/with this permit on: p�
Date of Disposition Place of Disposition ir/1� �A:1 l 7e l�l�
(address)
W
OC (section)/ (lot number) (grave number)
pName of Sextqp or Perso 'n Charge of�Pizises
Z (please nt _ �—
W Signature � ( )Title /�,cW 20M ��/'/
DOH-1555(9/86)p 1 of 2(formerly VS-61)