Caldow, John NEW YDRK STATE DEPARTMENT OFHEALTH ��NB�^��U � ����)����^� 0�x��8��^�
V�dRecords So��n ~~~~~ ~~~^ ^ ^ ~~~~~~^~ Permit
Name First Middle Last Sex
Date of Death
Age If Veteran of U.S.Armed Forces,
War or Dates
Z— Place of Death Hospital, Institution or
.:Uj City,Town or Village GLOVERSVI LLE Street Address
Manner of Death Natural Cause Ej Accident El Homicide [I Suicide o Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Death Certificate Filed District Number Register Kum er
City,Town or Village GLOVERSVI LLE 1701
332
� Burial Dn1a Comeoe�orCmms�ry
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�1Cremation ""~'"s~
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F] Removal and/or Held
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--'-Point of------u) F1(L Date
F1 Transportation^ by Shipment
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tination
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Address
El Reinterment --' emetery
Permit Issued to
Registration Number
Name of Funeral Firm REGAN 9 DENNY FUNERAL HOME
01602
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
-18-92 Registrar of Vital Statistics
Date Issued 12
1701 Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
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