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Blake, James NEW YORK STATE E RTMENT OF HEALTH - ''�* 3.7 Vital Records Section Burial - Transit Permit gigiii Name First Middle Last Sex A E S -Aor.o R_GA g LAKE MALE €€ Date of Death Age If Veteran of U.S. Army 0 For, » `1Y\9 -1 c C7(' Q$ War or Dates N A i Place of DeathHospital, Institution or City, Tewn er Vilege c kE;RE,CNRp Street Address E LL t �a,y,1TfiL Manner of Death 2 Natural Cause El Accident 0 Homicide 0 Suicide Undetermined. ri Pending Circumstances Investigation Medical Certifier Name Title RULK L. .-TEA)60•5 -A''`/. Address Death Certificate Filed / District Numb ' Register Number City, l ewn of V je • (�-\E N ECTRD �-I Date Gernc-tcry or Crematory . ❑burial ` \tNt- cD..3 ) 2-bin p V\t'E \I1 EL3 CgEInkTbt�kLurti Address tUCrematien A.\ p LL_RKE(=.. P-S), RU. EsE,14. S',t /4a. ) `1 ELLS oR-lZ.. Date Plate oved 2❑Removal and/or Held r• and/or Address FAHold Q Date Point of oi 0 Transportation Shipment a by Common Destination Carrier Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number gig Name of Funeral Home c-c T 1,3E2At E} \xyc , ©i n . ° l Address `tc) `\(`c,©r (_ Lrv. -, - LPrtte OKO-E )l ED ` i. 1 ag►Ls' ill• Name of Funeral Firm Making Disposition or,to Whom 11 Remains are Shipped, If Other than Above Address f , Permission is hereby granted to dispose of the human\rrema s r' ed a ovens i •icated. iiig Date issued '�3'" CLRegistrar of Vit "tatistics �� l, -topriti� (Si natur,) aiii District Number (S U Place LIL t I t ,(.. �I ✓) "/ ,i:iiiiii I certifythat the remains of the decedent identified above were disposed of in accordance p with this permit on: f- 6 Date of Disposition C 4 4.1 L Place of Disposition ,r.2 u.,.:., C;i-e,-...:. fer i 1. 2 (address) Ca CC (section) (lot number) (grave number) Name of Sexton or Person in Charge of Premises t 1-,-, . Th.,-,rY aT z y1 (please print) W Signature t 1./14,, ,4 \r .+. '" Title r( t't- r DOH-1555 (10/89) p. 1 of 2 VS-61