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Hance, Marnette NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit First Middle Last Sex M ar n e A--\- e. G'n C e 1= Date of Death Age If Veteran of U.S. Armed Forces, ,,11 o\ 1 15 \ w►LI 103 War or Dates N Ilk JName Place o eath _ Hospital, Institution or City, own r Village Fa ra' El C\►oc1 rck Street Address for-- }t4Sbei Nwrsi nq gpm e D; Manner of Death V Natural Cause 0 Accident D Homicide 0 Suicide El Undetermined nding U. Circumstances Investigation unt Medical Certifier Name t Title ci �2rncrd(7 U',\o„, r:Grn ` ,J Address nn `W\ e_ckr- (2- d ©U ODan J �/sba,ir� i „ I Leo-)Death Certificate Filed 9jtrict Num r Registe umber City, own r Village F r- E i ,YQ n1 51n5 ®Burial Date cJi , 11 Cemetery or Crematory Z(�1`� Pint_ Vitvo e_ernekery ❑Entombment Address OCremation Q Vt•C 6\S\Os lin) A `J 1 2.SOL4 Date Place Removed ZZ ri Removal and/or Held f and/or Address Lt? Hold 0 ' Date Point of N❑Transportation Shipment at-3 by Common Destination Carrier Q Disinterment Date Cemetery Address Q Reinterment Date Cemetery Address Permit Issued to Registration Nijmber Name of Funeral Home HGy nu d , 6cx:ker Einc'.c GL1 fk) _ Q I I 30 Address `I 1_aky Q C S. , a L„eenSbu,f y , ti e vv yur L 12 si v LA Name of Funeral Firm Making Disposition or to Whom F- Remains are Shipped, If Other than Above 2 Address lr us tar Permission is hereby granted to dispose of the human e ins described above as in icated. Date Issued III(p l _t)I i Registrar of Vital Statistics Y , o (signature) District Number E1 3 Place I t-idt FrYti- of t- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: 2 .1 Date of Disposition 1 /1 7/1 4 Place of Disposition Pine VIew Cemetery 2 (address) tat Hudson Sec. 2 8C 2 CC (section) (lot number) (grave number) aName of Se on or Person in Charge of Premi Connie L. Goedert (please print) iti Signatur Title Superintendent (over) DOH-1555 (02/2004)