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Lieto, Evelyn ----- .4 a 14 NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex t.V E‘. ( N tkFge�A I,�1 E.TO 7E M A►I",, Date of Death Age If Veteran of U.S. Armed Forces, " 1`\N-y L DO(a $I War or Dates p '1, Place oiCDeath 6wr1 6+ Hospital, Institution�or uj Gay' fter Village gotz-rm, Street Address f1 r71 LAkE, tk-oRE 9R\vC 0 Manner of Death RO Natural Cause ❑Accident ❑Homicide ❑Suicide El Undetermined' ❑Pending W. Circumstances Investigation tu Medical Certifier Name Title 0 mE.PO ) ERy�At ``7 Address U A3btait3 ,, V AL-cN C.61\v-vE,R ) (�DL-imi Lf�N.➢1 N G `h 1 a,$ Death Certificate Filed District Number Register Number , Town or Vilage ZoL-CbtJ iig❑Burial Date Crematory ['Entombment Address '2Cremation ((?U RkE(. I9. � C v,E ,ty EcxR<c� ,`(1 ELD '`' Date Place Remo vet At:IP.- Z Removal and/or Held 3 mg and/or gm5 Address fl ▪ Hold 0 Date Point of Q' Transportation Shipment O by Common Destination Carrier Q Disinterment Date Cemetery Address Reinterment Date Cemetery Address al Permit Issued to Registration Number Name of Funeral Home� / U tERAI._ .s—E ‘ NC, 01`1 l©� )Address q 0 'MD t3 j7,A Lwk. �T) LAW-E. C- Rc . )-t)Ex-0 R_ \ ag�5' Name of Funeral Firm Making Disposition or to Whom U � 1.4 Remains are Shipped, If Other than Above 2 Address U ` Permission is her by granted to dispose of the human remains described above as indicated. Date Issued 0 6 Registrar of Vital Statistics ZA--14--r-e\ , ,6, _ (,�gnat e) gli District Number Co Place 4.1_, -;:-,,,._,(4)--AlLe_e_6 , ----)1-- __, / ) S2 /C't I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: t ttt Date of Disposition 5'/g/V b Place of Disposition P,.,t.i t_,., Csp,,,,,c-1-i r,v,,- 2 (address) w 0 CC (section) (lot number) (grave number) ci Name of Sexton or Person in Charge of Premises C►nr,s Sonoe z (IL (please print) Eii, Signature �L Title Cr e f (over) DOH-1555 (02/2004)