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McElroy, Norma /1Z7 NEW YORK STATE DEPARTMENT OF HEALTH. w Vital Records Section Burial - Transit Permit Name Firs Mid a Last Sex Date of Death Age If Veteran of U.S. Armed Forces, `7// 6 77 War or Dates /f a }:- Place of Death Hospital, Institutio r y� City, Town or Village'j©� }/97/f ,� Street Address /Yi�C� ,....CT624�5 / z/45/1 0, Manner of Death-0 Natural Cause ❑Accident ❑Homicide ❑Suicide El"--i Undetermined ri❑Pending toCircumstances Investigation iii▪ Medical Certifier Name Title CI ?/fMV ://///-h40 127 4 - Addre �/� 9 _ ?` 2 �/4 Sj` / /s R ter Num Death Certificate Filed / District Number g City, Town or Village 6/CAS`/5j/l' �6D'/ `S 0 Burial Date Cemetery or Crematory /� �,�/� ❑Entombment 3 S� '" G " " , �l/IG�,,, (1,6/97, � � Address Rtremation aUE&� / /° Date Place Removed z❑Removal and/or Held and/or Address �=" Hold in 0 Date Point of Di❑Transportation Shipment 0 by Common Destination Carrier ❑Disinterment Date Cemetery Address ❑Reinterment Date Cemetery Address Permit Issued to Jo Number 4 Name of Funeral Home /f//9- /9� / �� � ' /,�,�� -- c. 4779 Address `/ L/97.vYE/7, &,( /may /c�4�P' Name of Funeral FirmF Making Disposition or to Whom Remains are Shipped, If Other than Above • Address CC LF Permission is hereby ranted to dispose of the human remains described a ov as i c ted. Date Issued l5 Registrar of Vital Statistics A ` (signature) District Number`%J/ Place - AS X�//4 XV 72 / I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: ILI p 3 S o (0 Dispositionpi i)i) Jr:- (',I6 +e V . • Date of Disposition � Place of � C�R_,�Y�. IZ/ (address) LE:I CO CC (section) (lot number) (grave number) ta Name of Sexton or Person in Charge of Premises '>,d,.tz-e.,- 6 czta��� 6 (please print) La Signature G-�� a Title ,F� t/ 4 f-C) 12..._ (over) DOH-1555 (02/2004)