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Elethorp, Berenice NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name Firs j Middle IIIIIIIIII ,� ) }ast Sex �Dc-ren► c /_�Ertho 0 / P14�, € Date of Dea Age I If Veteran of U.S. ArmedlForces., 21 /4 7 1 War or Dates • Place of Death Hospital, Institution or ,�— /)v City, Town or Village Oa C(h , 1 4 0 n I Street Address / 1 GoeSevd.Sj N Manner of Death©Natural Cause Accident Homicide Suicide Undetermined Pending Circumstances Investigation Medical Certifier N me (� TiUe,, pc� ,JCt ev4 m 0 A/ddd►re$ �///�J o ,"--/ lir /2,2k iliil Death Certificate Filed District Number Register Number ,iiiiiii City, all or Village l/c or►d/e v a `S` ci I Date . s Cemeter r Crematory El Burial Jun 2 `19a— crIete C)!ew 6,-e.�0.-la 0 Address ®Cremation QLt ceekr ��I J P c.(/ Date Place Removed 2❑Removal and/or Held -- and/or Address IHold 0 Date Point of %Q Transportation Shipment 5 by Common Destination Carrier Disinterment Date Cemetery Address Reinterment Date Cemetery Address 'i. Permit Issued to Registration Number '<: Name of Funeral Home COn ne v + (=, In el •iS CO c� 1/ € Address 2 -ihe - Jo Lies. Q / /t c0et:iF d /Ut /2�3 _ ii Name of Funeral Firm Making Disposition to Whom tt Remains are Shipped, If Other than Above Address la Permission is hereby ranted to dispose of the human remains/)describe by ye as indicated. Date Issued /L 31 Registrar of Vital Statistics /)'k CC � �f VC"L--- (signature) District Number 1,5 / 1/ Place Q1 —e �N Ce_tJt v _20y• / sr s- 3 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W Date of Disposition J`t� 7'(Place of Disposition/ i fl���/€� Cd ROA4I9 7=7.-I( /i1i 9 2 (address) CC (section)` p (lot n tuYber . ) (grave Name of Sexton oror Person in Charge of P emises )DhJr9/,D A4,7 / //9 kJ number) (please print) t Signature EA4Title Q' S f r DOH-1555 (10/89) p. 1 of 2 VS-61