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Hughes, Ethel /) btar NEW YORK STATE DEPARTMENT OF HEALTI?' Vital Records Section Burial - Transit Permit Name First Middle Last Sex V -0E4_ _8EATR C.6 LlG-I-kE TFrnAL..E Date of Death Age If Veteran of U.S. Armed Forces, c)—. 9.it War or Dates q A 14 Place of Death Hospital, Institution dr City,hewn-er Village g_LENm pv LI, Street Address L_Et\c S {\LL S V\--0Si)1710iL us Manner of Death�Natural Cause ❑Accident 1=1 Homicide 0 Suicide El❑ Undetermined El Pending tii Circumstances Investigation ui Medical Certifier Name Title E, AN, A 11y `1-`f) Address \oo 'RW. --f,) -LE,t3s -VAL,LS) -n 19.8'0 1 Death Certificate Filed District Number egister Number City, TewtI erne 4..EKS Ail- SC.00 I 0 Burial Date Cemetery or Cremato ❑Entombment `ICY\AR_ 3) acc.,(o �tNE Nil Eu.) ErrA�RauYVL. Address ''�ff� ;:'Cremation a1 �01}&ER RV. QuE61.1SZtk `A- 1 a$0 Date ) Place Removed Z Removal and/or Held and/or Address tz CD 0 Date Point of 0`` Transportation Shipment G! by Common Destination Carrier Q Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number gig Name of Funeral Home \ c c 9 N.FR-AL tt5-rn E ) IN c , ©l'\ 10 >< Address q o `Th'b CALtk Sr. LINKS Q,t3 )`-r y ag 4s Name of Funeral Firm Making Disposition oo to Whom 14 Remains are Shipped, If Other than Above 2 Address IX. la Permission is hereby granted to dispose of the human remains describe above in a d. Date Issued 3 / 2) 0 b Registrar of Vital Statistics ,+ .7 .` (signature) District Number 5 b 0 i Place 6 S Tu 1 1 5 , my I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: k ILI Date of Disposition 3 "' 3•-- / Place of Disposition ,Ai\tE_,v1'� C 4-=:,-;M j4,1--oi, i (address) Ili to cc (section) (lot number) (grave number) ci Name of Sexton or Person in Charge of Premises ea- -G2-L4 6,1 9At .4-- z (please print) Signature 6_£ -vc, G� Title aRE,t4,+6 (over) DOH-1555 (02/2004)