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Riley, Marilyn NE`V YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last S t 1-- /M e LI 2€k C R 1 LE "1-ElY1B LE mi Death Age If Veteran of U.S. Armed Force , aa , c;- }11 gI War or Dates NPs 1-!: Place of Death Hospital, Institution r , City, Town-er Village C�(,EK5 j_,L,s Street Address i}-F r� .5 -T C j ety.s click LLS Manner of DeathNatural Cause ❑Accident 0 Homicide ❑Suicide ❑Undetermined ❑Pending l Circumstances Investigation W Medical Certifier Name , Title G jU2�ANNE PRE �l `'h9 Address no La Agtze0 1) (LE1• S -- ALLS)'Yl U LagD1 Death Certificate Filed District Number U Register umber City,Town-or Village G-(sty S -FA Li__ S _ S(i d( 0 Burial , ❑Entombment ilrasoppretteet as ) ( 0( t Vi etE NIA . frA E- I L� R _ Address , 4 ❑Cremation \ Cu Ak€(� ��. u EEN.SCi u - � l t� o"4 Date Place- emo ed �1 ❑Removal and/or Held �= a Hnd/or Address to old O Date Point of iEl Transportation Shipment G by Common Destination Carrier El Disinterment Date Cemetery Address ❑Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home j 4/,4,0 E P-f}t _ E 1 rC, O) (p 41 Address 9 o T,n t. tilik Si-' ) /.4 kE e DR_G-c --'n 1 a% i+s'" Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above a Address te. W. Permission is hereby granted to dispose of the human remains descr'bed above indi Date Issued © 23 /( Registrar of Vital Statistics .-gki - �tZ (s nature) pp District Number 4-(off/ Place o7er . /--;74 NY I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: 2/28/11 Pine View Cemetery Date of Disposition Place of Disposition 2 (address) 2 tlii Seneca 5D rE (section) (lot number) (grave number) ci Name of Sexton or Perso 'n harge of Premises Michael Genier 2: (please print) i Signature Title Superintendent (over) DOH-1555 (02/2004)