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Blanchette, Judy # z33 NEW YORK STATE DEPARTMENT OF HEALTHY = 14 Vital Records Section Burial - Transit Permit Name First Middle Last Sex `i Date of Death Age If Veteran of U.S. Armed Forces, A `NV° lX i.1 War or Dates Place oeath , 1 Hospital, Institution or City, (ft.Dow�t pr Village N Np Street Address Manner ofbeath L,2 Natural Cause E Accident 0 Homicide 0 Suicide 7 Undetermined 7 Pending Circumstances Investigation IA Medical Certifier Name Title IA �L�S \)CGCQQD � Address • C0 \e_ L-n � ,3 9 VCXQ =, \-25;k\3 Death ificate Filed District Number egister Number City, own r Village �CC�� ��j \�JSC 3 ' W6 <`'❑BUrlal Date cr Cemetery or Crematory [Entombment I\�l2-©\v c*w�,\)\U� icoi0 <en :NIAddress • ` ' remation �� t.r 4- QUe4x\6\ 1 \ \ Date Place Remove 0 Removal and/or Held and/or Address Hold Date Point of ftE Transportation Shipment a by Common Destination Carrier 0 Disinterment Date Cemetery Address Q Reinterment Date Cemetery Address Permit Issued to .--� \ �Re istration Number Name of Funeral Home t X�C . �. `L\\ Address \\__ lip Name of Funeral Firm Making Dispositioh or tokWhom Remains are Shipped, If Other than Above Address ea Permission is hereby granted to dispose of the human remain described . •o : a dicated. li Date issued 3 ^ iq - 1 g Registrar of Vital Statistics aft signature) District Number i5 93 Place 91)iunylio �J ;.,: I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition 31 Z( lt3 Place of Disposition ei.v,-, /ru, (address) (section) � (lot number) (grave number) .:1.:. Name of Sexton or Person in Charge of Premises 6 4,, i— ) 't'1`�' (phase print) 414. A ,.„„;.:„„, Signature 4- - Title (R04 1l (over) DOH-1555 (02/2004)