Blake, Sasha NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial = Transit Permit
; Name First Middle Last 1 Sets
> $aches. Ann ) la.ri bake. 1 fe.na Je
< Date of Death / / Age I If Veteran of U.S.Armed Forces,
1l$( 20/ 41 I War or Dates
Place of Death / Hospital, Institution o �' ,r r
. City, Town or Village GI CAS FQ lIS Street Address ICE s are( -C
ci Manner of Death Natural Cause n Accident n Homicide 0 Suicide El Undetermined n Pending
Ili `�c' Circumstances Investigation
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Lu Medical Certifier Name Title
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Address
l 6v Pa e oc S ref, Glens fiat l s n ear �- l(f1 l'1 Yd��
Death Certificate Filed j District Number I Register Number
City, Town or Village I S 60 1 1 6
❑Burial Date 11 Cemete or Crematory,T
;,: ❑Entombment r ' a I(� l r/l-' �('2"`� urt/vLGd ry
Addrss c L
[Cremation 4C r- Qoas.1 ��.4Ja,lls b (S.e.A.)` or-V._ (2-K 1(
Date ` Place Removed
CRemoval I and/or Held
and/or Address
e��
Hold
Date Point of
Q Transportation Shipment
by Common I Destination
Carrier
Li Disinterment 1 Date Cemetery Address
Reinterment Date I Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home . �Lti- i::s�L; 1 1- o j1`l C t\ Cam`
Address �.,
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Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
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114- Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 1 ) 6 1 1 7 Registrar of Vital Statistics W
(signature)
District Number 56 01 Place 6 �A.„.s 1 1 S ik1
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I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
la Date of Disposition ( 19 I l7 Place of Disposition gig,' ot...
(address)
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LE (section) / (lot number , (grave number)
ta Name of Sexton or Person in Charge oX Premises ^rr �""��
1 (please print)
u 4 Signature �v-- Title Mt
(over)
DOH-1555 (02/2004)