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York, Charles NEW YORK STATE DEPARTMENT OF HEALTH y If k St Vital Records Section Burial - Transit Permit Name Firs addle Last Sex Date of Death f Age / If Veteran of U.S. Armed Forces, g/ a i l/ I b (o a. War or Dates _ #- Place of Death Hospital, Institution or Z City ow. +r Village Ou►ee-^&ST Street Address i`f Rrrc k ev..k W Manner of Death 0 Natural Cause Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending Circumstances Investigation ui Medical Certifier Name Title El)c-( €L le, gaM A,r"e Address 3 741 M4`.,\ 5� Uri )Sti N 7 1' -�5— Death ificate Filed District Numb Register N tuber City, tiqw,.br Village aie4 sS,� —µa S(,Sl (( 0 El Burial Date ( Cemete or Crematory 8/�/ ao• ,, �;e� CQ,tiaot ❑Entombment Address ,_'� 0 ©Cremation i ems.s S�r 0 ( Date (. Place Removed 2❑Removal and/or Held and/or Address 1= Hold U) 0 Date Point of t Q Transportation Shipment Et by Common Destination Carrier Disinterment Date Cemetery Address Reinterment Date Cemetery Address ,„ Permit Issued to Registration Number Name of Funeral H GA3f8r t- Ag..Pa L NIL D" `D' V Address GG( 7 U9er•.k.tr Aug, CdP: k7 la�' _ Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Z Address ilk [t Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued Tit) ``Za,it Registrar of Vital Statistics A c.t. (signature) 111111111 District Number Si, Place QU e enS b ti I certify that the remains of the decedent identified above were posed of in accordance with this permit on: Z > Date of Disposition $Oily Place of Disposition fi7,2(Le ,-oL (address) W U) CC (section) (lot num� er) (grave number) 0 CI / Name of Sexton or Person in Charge of Premises / i+ "L P.-4i /,' (please print) iti Signature /,�� Title Fryl?,F►nik,— (over) DOH-1555 (02/2004)