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Sipe, Madeline NEW YORK STATE DEPARTMENT OF HEALTH �� I/Did' Vital Records Section Burial - Transit Permit Name Fir t Middle (� Last Sex �N4 /ijue_ /I , N1/ip-e- rrl,il_g_ Date of Death Age f Veteran of U.S. Armed Forces, `�- �3 - 9-�' 7 War or Dates 4'-j ✓&l l Place f r) ath _l Hospital, Institution or! �� Ci ILI , Town r Village EC-�J SDI" Street Address /DV eMAfi ff // -70 0 Mann o Death (Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undet mined ❑Pending W b�" Circumstances Investigation W Medical Certifier Name Title c1dre§ Ni-f;41 4oe, 5 c� 'A/a . /tee Deat -• cate Filed 5>: Distri,c(pct Number Register Number City, ' own Village C,j MZ''�— L$r 6 >_ ❑Burial Date etery of Crematory ['EntombmentI°2—Ail—, /cg A•�eV/G�tc1 he.4.7 A (©l--/ Address (Cremation 0 Q-ert).$ 4 v k► ^ Date Race Removed Z❑Removal and/or Held and/or Address t1 Hold 0 Date Point of 05❑Transportation Shipment L3 by Common Destination Carrier ❑Disinterment Date Cemetery Address ❑Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home 0.}4I-'/ ,/- /l�/d /U!f-l/'�9t'igs>-e_ e3(JS^ 17 Address t0.7, 0AA n/'�- i - /at ,'.-- 0 K ! Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above 2 Address I LEt !` Permission is hereby granted to dispose of the human re ' s described abo as indicated. � /Date Issued / -/6. Registrar of Vital Statistics �yj2 ca ��r� (signature) District Number JS� (Place rL A 11/Z____ /u/ , I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: 2 111 Date of Disposition/I-JQ t? Place of Disposition f;r-rt- i,t") Cftr*iory 2 (address) LU 0 CC (section) (lot number) (grave number) Name of Sexton or Person in Charge of Premises } z (please print) 41 Signature Title Cre-,,i cr (over) DOH-1555 (02/2004)