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Montgomery, Lucille d NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial.- Transit Permit Name First jii /Middle /� i Last Sex L --,:. J ...,c, .. Date of Death Age If Veteran of U.S.(Armed Fors, I i (d 1 / of c SY War or Dates " - - 1,4 Place of Death Hospital, Institution or _ --, i• TioTown or Village �g.1e,,5 -1II r Street Address ' 't -t r rS T 'nner of Death❑Natural Cause ❑Accident ❑Homicide ElSuicide ❑Undetermined ©Pending W. Circumstances Investigation di Medical Certifier Name Title II . Address . Co Q t o t U 4.44..4 N 7 D Certificate Filed district Number Register Number ity, own or Village �gL...„,� 5-(�01 J Burial Date Cemete r Crematory ' 117 ,. / a,I)6--- ,,,,,v,•c,.... c......r.—4,7s---- :❑Entombment Address [ Cremation ' Date Place Removed Removal and/or Held fl and/or Address E.VI O Date Point of tL Transportation . Shipment Q by Common Destination Carrier Ni ❑Disinterment Date Cemetery Address E Reinterment Date Cemetery Address : Permit Issued to ' Registration Number Name of Funeral HopG,�S ,,nC.p,a.k H.-0, _ ,� 06 `-/-`rir Address 7 �/ /' • Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address . r til Permission is hereby granted to dispose of the human remains descri d above s i -nn' �t-ed. ``' Date Issued it ka/) /a0/� Registrar of Vital Statistics / /, " -1-ovt ' (signature) District Number S�° I Place 6L4-/-7--I:vc A) y certify that the remains of the decedent identified above were disposed of in accordance with this permit on: • Z ill Date of Disposition I/ /i /(Y Place of Disposition Pipe. v,(Ad (.,ri,mg+ocy 2 (address) w til. #C (section) (lot number) (grave number) Ci Name of Sexton or Person in Charge of Premises J efrte,J 39jx i f ..5 z (please print) • Signature di r • , - Title �rtr►r C T (over) DOH-1555 (02/2004)