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Black, Florence A. NEW YORK STATE DEPARTMENT OF HEALTH Banal ' Transit Perm Bureau of Vital Records Name front Mlae@ Izst ses Nre aw Buda femw Ow of RM AM! If Velerenof O$/.rmea tong MYw WxxOws Plea of CodM1 Hou iW,liondu na, 2 Care raw,or Wilay ForeL4e roar surrounded nTarLtlFFULove, Lnrg Lakenown New"Fil ] o Manners Nam, ®xwaorm ❑Harem ❑wmtw ❑m'mme �wdnerminee �h,alog W Cirzumstaraes Imesti W Medical CenMier Name TOM C MaWevmw Career Address PO.We Bad,Iryar teed,New Yak 12M CenA[ehNim Filed Dinht Number Rmmr Number Chairman uVOlest, LongILa 'dust 3 71Buaal Dw Cermrcrydremaory. or Oman"Name ❑Emrmbmat oeatnoai PbmvMwcrwrMay Address ©[remains amrrwyrrwn, Hew York Eltermation F1hmr.a ow Puahmoead error aNbe xew Vi Hold Address O Of H QTran[ponxon Nk ShIPneM O MCmnmon wsaration Carrier �Fundament Fine 4neNry Mdrtas Annuitant Date CemdkrYA—M Perme issued to Rdpnmbn Needed Named Frrnamt Home hHller Frm'WHam tine Mara wsl Ny,RM*W InOWi W New Ya It Named Funeral Nrm Mauna Diem:Nan or m whom N• R,m,,,mmmdLffOihdmnAm, q Address w w u Permission la M1aWy grmtatlrotllepgn of The human remains tlXbetl above as lnwratwtl. De,Issued calrolM Rearms"OF vital stninias 0 lis @eac LeGlenl(Elstrannally SlAeam 4lewwel Corral Number 3M8 axe trig tee, now Yak anev the the rem ur of the dao em bound!ebme were arsmaa of in awardamead with this parmb on: W Date m D,, osilio, fin IFFar Made of oispraiurn i3j. Atli Mm s, w It t tunmaa,'c row i $ Namam sew,nrpematmeb.ryd Nemi� � b � w�N f ewe„wN sirs rite DOHa5550AIN!'tdl Nbfic Heahh Law Sec.4145(M) U12739 Receipt i/� l Hunummmainaof �6enca Blab . delivewlon— , 20 Pma Pew Cemeuay / Repreentmg the fiineml home nem oont perch Funeral Ovecmn Reg or bcrnmp /OSo/