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Van Horne, Norvan NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle L st Sex�t,� O/ �>A V /LJL>' Date of Deat Z 2- A e9 If Veteran of U.S. Armed Forces, / War or Dates G`1 — y 2 s j- P P . e of Death / Hospital, Institution or dopown or Village GL6s',�)S Fes, c Street Address ‘A z , /Ff6?9"L c , CI ' -nner of DeathIKNatural Cause ❑Accident ❑Homicide ❑Suicide ri❑Undetermined ❑Pending U./ Circumstances Investigation tu Medical Certifier Name Title Address D •th Certificate Filed District Number Register Number City own or Village QL,(:5',,-i S FiyL�,& 5 6 o ) 6 -2-5 0-Burial Date Cemetery o f remso atory Entombment /L J/3 76 6 / r,Je V/G�-J Address ( -. (Cremation ej .) .&‘,•— s Q Ai � 0 06-L-,Date Place Removed t ❑ Removal and/or Held ► and/or Address Hold 0 Date Point of ❑Transportation Shipment f by Common Destination Carrier Q Disinterment Date Cemetery Address El Reinterment Date Cemetery Address Permit Issued to _ &WC— Registration Number Name of Funeral Home ,v, yz I/ \ &- / u1JL C)/! 9 y Address 6i----ris24--•// '�, 0 U 13 UYL-c , ,,A.�' , /2Name of Funeral FirmDisposition or to Whom Remains are Shipped, than Above • Address IX '7.1 Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued / 2,/ i 3 ) 0 6 Registrar of Vital Statistics 1423. ,a...-4-A c-t.c.�` a f i..i (signature) District Number 5 e,© ) Place 6 .5zMS ct \\5 1 NA-? I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: ill• Date of Disposition i.//iy Al, Place of Disposition (l,n.Qv.'i,. (rW,it(Jr; v yi. (address) W CCU) (section) (lot number) (grave number) Ct Name of Sexton or Person in Charge of Premises CI, r, s Seon e( 2 /� (please print) Signature iLi / 2.M'c" Title 1. " kt`r (over) DOH-1555 (02/2004)