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Towers Jr., Harold NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex tek tatLc.LD £ 1 ©,.a 0_5 7rjL Date of Death Age If Veteran of U.S. Armed Forces, QvC:,%›!›? LI a.6%% _ % War or Dates 19 5 1- Iq 9 .}- Place of Death Hospital, Institution or Z City, Town or Village Co Q...t wiz'iA, Street Address a� `Q.A�..,,,N� S Manner of Death Natural Cause 0 Accident 0 Homicide Suicide Undetermined Pending W Circumstances Investigation WMedical Certifier Name Title Gct; A."G Sz..>ZAo 1-1- t\D Address 604 tPt-r`+ 2 k1Ii: Q.4)e_t r i4 N`-• t av � Death Certificate Filed District Number I Register Number City, Town or Village ❑Burial Date Cemetery or Crematory 21 1 of� co-1 \Ae- .) ( tz Ely, 4 Q. ❑Entombment Address Li (Cremation Q.,+ .E L 'b A. 00 c_e.�s r1 13 11.., a K Date Place Removed 1 Z❑Removal 2 and/or and/or Held Address I Hold CA C) Date Point of tch 0 Transportation Shipment 0 by Common Destination Carrier Disinterment Date Cemetery Address Reinterment Date Cemetery Address -77 Permit Issued to — Registration N mber Name of Funeral Home JCt-N-5 cnott , c J L Ai j L I ("Z-- Li k4 Address i SaE, Qom, n1,1 Ave Ccz xm Ii.. 1 sla. Name of Funeral Firm Making Disposition or to Whom / f Remains are Shipped, If Other than Above 2 Address tr tfi 4ti. Permission is reby granted to dispose of the huma mains scribed, bo mated. Date Issued Registrar of Vital Statisti C. Q/L (signature) District Number Place Ots---"Ze_y" .. I I certify that the remains of the decedent identified above were . posed of in accordance with this permit on: Z ILI Date of Disposition if II. lit Place of Disposition LU_, (1141,1k, 2 (address ILI tfl ilr (section) (lot numb t (grave number) Name of Sexton or Person in Charge of Premisesr,. 1-, a�� ' (please print) tit Signature G-� — Title '���+�, (over) DOH-t555 (02/2004)