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Ash, Rankyn * , 19`. NEW YORK STATE DEPARTMENT OF HEALTH,. . Vital Records Section Burial.- Transit Permit Name First Middle Las Sex Ili 2ek A Vt.".. S tit iiiiiiiii Date of.Death ( Age `� If Veteran of'U.S. Arme Forces, 3 = ©17 z5 . . .War.or Dates - P - e of Death -- Hospital, Institution or p own or Village 6 14 -F.,\'c- Street Address 6 Le'" -i-'t 1f- 1-k%, a 'anner of Death oarrff Natural Cause 0 Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending IllCircumstances Investigation Medical Certifier Name /. Title h( it` ' C ,,,..,i^ s 1 , Im b Address _ N D h Certificate Filed � - District Number Register Number iiii i own or-Village C L.�, < � A1t, S ' 01 1S o >,; Burial Date 3Cemetery or Crematory ?• iiiii ❑Entombment Address iffi QCremation u Date - • :' Place Removed 2❑Removal and/or Held and/or Address #R Hold fl Date Point of th❑Transportation 1. Shipment • Q by Common Destination iiiiiiii Carrier li ❑Disinterment Date Cemetery Address > • ;❑Reinterment Date Cemetery Address Permit Issued to P-8%'sr ."11V �'' j�. Registration Number • - Name of Funeral Home ' r• laA6, ,-.L t Ic:+Ac1e, 41LJ . Address - 7 5 ke AA0.-eN e. 6rIv,-Lk f I) c - : Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above — Address 1 . ILI P": Permission is hereby granted to dispose of the human remains descri d above s in ed. '' Date Issued //v /,7 Registrar of Vital Statistics -tl X (signature) District Number Lc c.9/ Place L9 Z,a.1r•-r°k I Lf' ) A' ``' I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: • ttl Date of Disposition ;3J1��17 Place of Disposition ��L(„7�'p� �P��/7 tea / (address) 0 CC (section) (lot number) (grave number) = ' Name of Sexton or 'n Charge of Premises \IA iicvo, �4-04c4-c.lzG' 2 (please print) Signature Title L./'Gmc,/ 7 (over) • DOH-1555 (02/2004) •