Wolfe, Rita NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
i Name First Q Middle Last
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Date of Dea Age I If Veteran of U.S.Armed Force
IP-f f�- R le • I War or Dates
Place of Death rmrital Institution or
City Tow r Village �t :Zsild l3 ' ' cStreet Addr S, 3,3— Cou,.. 7 (mil-4c� kej
Manner of Death-Natural Cause Dkcident ❑Homicide El Suicide ri Unktelermined Q Pending
Circumstances Investigation
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la Medical Certifier Name Title
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Address
Ws,i C -J e L em s Fez.ta Al
Deat icate Filed7Th I tt umber Ole i er Number
City Tow r Village v '�SQ (g '�
l•El Burial Date Cemetery or re eTtor
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0 Entombment Address
` (( Cremation
Date Place Removed
CRemoval and/or Held
and/or Address
Hold
tta
Date Point of
gi❑Transportation Shipment
by Common Destination
Carrier
0 Disinterment I Date I Cemetery Address
`? E Reinterment I Date i
Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home .\I'N(2 X i"Ne.:_;i \ hoc' '{- C t l L
Address
It Lc,c e X- S-k- C t r(_S\S`�:..:_ 1 ! ic•z,\k I i C LA
l Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
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C" Permission is hereby granted to dispose of the human remains described abov1 ars'ndicated.
Date Issued& I IS"b}t Registrar of Vital Statistics �C�_��' .,
(signature)
District Number <(..6K
" Place Jo O $ nc„.0._„,im,
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I certify that the remains of the decedent identified above were disposed of in accordant wit this permit on:
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iiii Date of Disposition?--( -te Place of Disposition pirk, Ur.`,w C r,;r^ires
� (address)
tfl
(section) (lot number) (grave number)
0 Name of Sexton or Person in Charge of Premises deft e-Y 5t5) re.c
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t Signature Ay.- t� .� Title -fufhet
(over)
DOH-1555 (02/2004)