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Miller, James # Z3 NEWYORK STATE DEPARTMENT OF HEALTH I 4 Vital Records Section Burial - Transit Permit Nam . first M ddle At I Sexgear_ /2 .34 Date of Death Age(— If Veteran of U.S. krnied Forces, Q/- Q E% ' / i ; War or DatesP Place of Death Hospital, Institution or City, Town or Village N LC+PjA Street Address I? 7 e‘p$S/C+,u R8_, tij Manner of Death tural Cause E Accident L Homicide C Suicide EI Undetermined E Pending Circumstances Investigation Medical Certifier °Name Title f u 5, -/'/ - J d_ r /i O Add ss in Death Certificate Filed I District N m r ! Registter Number City, Town or Village L� '� V -P,o i r Date ,r� etery jor.Crematory / ❑Burial Vt-" ©=_, — di jc� I ve V eio eq�..447 leay�/ Address :::::Cremation ! ,� /au�y Date �! r Place Removed tEl ❑Removal and/or Held 1.g. and/or Address Hold Q Date Point of N ❑Transportation Shipment G by Common Destination Carrier Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to ._--� ��� / / Registration i MVO— 049 umber IIIIIIIIII Name of Funeral Flomeg 1 ' J ,peiA IgIlAddres � 'l J-A k lox/ 1� Name of�uneraFirm Makin Disposition or to r 9 P Elm Remains are Shipped, If Other than Above Address rc IA a « Permission is hereby granted to dispose of the human remains descri abo as indicated. Date Issued O/--p 1.� 16fiegistrar of Vital Statistics // j,(1 III (sign r )' xii District Number 6S Place A)4tre' 9/ -- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: f- W Date of Disposition us ]I t Place of Disposition U.i /, A— (address) ILJ (I) CC (section) Alot number) (grave number) Name of Sexton or Person in Charge of Prem es n, 5.z,,{r z / (please print) Signature 1 Title ifz teirm, (over) bOH-1555 (9/98)