Duell, Albert 82/0
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name // / fiddle ci>4.,,
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LY of Death � Aged.. If Veteran of U.S. Armed Forces,
G` of c A 0/7 • War or Dates
}-, Placgfth l Hospital, Institution o
City own Village Fl/Z4�?.27 Gay/ ..Street Address Cs,�e (fir) 7-eof—
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p Manner of Deathatural Cause ❑Accident 0 Homicide 0 Suicide ri❑Undetermined Pending
W Circumstances Investigation
tu Medical Certifier - 7 1M/� n
Address /
g/ iP0 ik - C6 el/6-e-M /C,G-r711/ .7(/-7 /)" 0 "---
Death Certificate Filed District Number Regist6Number
City, Town or Village
❑Burial Date orcrematory
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El Entombment Address /)/
,k2remation (X(1--e S i Vic L/ -Xy ,,9_g z�
Date P ce Removed
❑Removal and/or Held
..- and/or Address
H Hold
0 Date Point of
05 Q Transportation Shipment
G by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to / Registration Number
Name of Funeral Homet0�,f may)�� 70e/� Z, -n C , Pc,///
Address
y n-e (1hts- -,/dt.)i2 /7 /)fi 7
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
,'; Address
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fl? Permission is h re y granted to dispose of the human rem - s d "scribed above as indicated.
Date Issued / / �j .7 Registrar of Vital Statistics Q.,
(signature)
District Number /6,c Place/ZJ0/1 e,-- ��/? 7/)
I I certify that the remains of the decedent identified a e were disposed of in accordance with this permit on:
p
ILI Date of Disposition 8A (� Place of Disposition gikicat-i-tor:,,_
2 (address)
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U,
Q (section) (Ctvr:umber) ( (grave number)
CI Name of Sexton or Person in Charge of remises 1�3��
Z (ple se print)
Signature JCS Title
(over)
DOH-1555 (02/2004)