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Waite, Beatrice • Nkfh YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name airst ii / og Middle f _ ., Last r Date of Death A If Veteran of U.S. Armed Forces, - ' I01() 13 War or Dates i-.. Place of Death Hospital, Institution or 6 Cityy, Town or 'lage C Street Address a Man Ural Cause Accicr 0 Homicide 0 Suicide EiUndetermined �Pending la Circumstances Investigation la Medical Certifier Name // Title ,/ /Gvt, /,�vjeci) • Address 3 ©� fe -; ..c�✓ �7 ems- Y/5-,7,7 /'.,�J iii:. Death -rtificate Filed C/ TTSteiNtgmber Re ester Number Cit , Town . Village (itA,�-0 '-) i 3 urea Date Cemetery or Crematory Entombment Address ❑Cremation r ke-z-• Date Place Removed 9.❑Removal and/or Held and/or Address i;; to Hold Q Date Point of iw Q Transportation Shipment C1 by Common Destination Carrier Q Disinterment Date Cemetery Address Q Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home /% 2ef_,, 7 , �//, 62/4 0 ;i Address y&-, .r. 6'-/ at.ie, e / 7.5'Lli,v-rfii .4/,t/A7 r-. , / Name of Funeral Firm ing Disposition or to Whom - Remains are Shipped, If Other than Above 2 Address cr to Permission is hereby granted to dispose of the human remains described above as indicated. Date issueda.{ I a013 Registrar of-iitai Statistics r )�-_ gI, �` . . (signature) District Number Place a ��,,L� Cs S"�''I � b � „,,.,:!! I certify that the remains of the decedent identified above were disposed of in accorda ce wit this permit on: 2 iti UI Date of Disposition 2/8/1 3 Place of Disposition Pine view r'en i- ry (address) tO tO Hudson Sec. 1 4C 2 CC (section) (lot number) (grave number) pName of Sexton or Pers in Charge of Premises Michael Genier T (please print) Signature Title Superintendent (over) DOH-1555 (02/2004)