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Whittemore, Evelyn NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First -, / / Middle Last I Sex �/ v �/<r�rr•a� i Jer ez-E'er Date of Death Age If Veteran of U.S. Armed Forces, 7//5-/9 49 War or Dates /17D if;4 Place o eath Hospital, Institution or n" ,// City, own r Village a� Street Address /J (/ia Manner of Death Natur" Cause Accident 0 Homicide 0 Suicide 0 Undetermined .. 0 Pending Circumstances Investigation Medical Certifier Nne, // � Title gi Address , to Filed istrict Number A.e,e -kteA-e-eZ r,' �71 Register Number >:: Death ifica .,--� ,v `3 City, odor Village 3z Date �'w/, Cemet y.pr Ore atory ,yam ❑Burial 1(/g �Od /..rii�j/ , --2 /6 i%,' - --L Address Cremation Date Place Removed Removal and/or Held ... and/or Address k' Hold >h 0 Date Point of N❑Transportation Shipment a by Common Destination Carrier _ Disinterment Date Cemetery Address Reinterment Date Cemetery Address [: Permit Issued to Registration Number Name of Funeral Home � m,1 - jle7-,..` {/-/**:),--4'..-j-1.--.-- 7. s >3 Address `L /2/ .,_,_.,7_,,,,_„7 `j !' /�eo/ Name of Funeral Firm Making D. position 6r to hom '" Remains are Shipped, If Other han Above 4 Address w Permission is ereby granted to dispose of the human re i described ab e indicated. e_ Date Issued 1 1(©(U Registrar of Vital Statistics ,(y ,4 7 (signature)pi � ur. :::::3 District Number5� Place �bwn O AA CC-* certify that the remains of the decedent identified above were disposed of in accordance witr this permit on: f- j. WDate of Disposition 7/+ /`..'G Place of Disposition fr (lc" r," L `�'terA fi 0`-` ,1-._ 2 (address) ill IX (section) ,- C(lot number) (grave number) GName of Sexton or Person in Charge of Premises L ITT` Ji le,./4 F 1 I 1 (please print) r-i Ui Signature L. -�n.1ts, . v1„,,, -"-- Title 1..-`' ,\.:40(- DOH-1555 (10/89) p. 1 of 2 VS-61