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Kristal, Baby A NEW YORK STATE DEPARTMENT OF HEALTH a" 1 Vital Records Section Burial - Transit Permit Name FirstB MT ale ast - S Date of Death Age If Veteran of U. . Armed Forces, �� - War or Dates 14 Place of Death - �� Hospital, Institution or Z City, Town or Village Street Address _1 "' L iiii ©. Manner of Death©.Natural Cause ❑Accident E Homicide Suicide ri 1-4 Undetermined 0 Pendi g Al Circumstances Investigation P Medical Certifier Name Title o I . a 0 `Iii Address iicss iy.e.e_,_, iis tAi\y , Death Certificate Filed `' District Numb j Register umber City, Town or Village ` .J J0(, / r Date Cemetery rematory 6,--4),,,,, ,, RRurial � 0 Address _Cremation Date Place Remove 0 ❑Removal and/or Held — and/or Address t Hold Eh 0 Date Point . aii Q Transportation Shipm- a by Common Destination • Carrier ElDisinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to . Registration Number Name of Funeral Home C) �� _ ` ` ? Ti[ Address "'`` Name of Funeral Firm Making Disposition or to Whom !w" Remains are Shipped, If Other than Above i Address f ilM Permission is hereb granted to dispose of the human r ains described above s indicated. Date Issued 4 Registrar of Vital Statistics /Qocc.k_csz. L (signature) District NumbeL6J Place / ' / / iini �1 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: f;- W Date of Disposition 4/8/94 Place of Disposition Pine View Cemetery Oueensbury NY 12804 2 (address) LU Mohican 86—D 1 CC (section) (lot number) (grave number) GName of Sexton erson in Charge of Premises Rodney G. Mosher Z (please print) Signature - Title Supt . DOH-1555 (10/89) p. 1 of 2 VS-61