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NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First if, iddle st ly14.7.4"
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Date of Death Age If Veteran of U.S. Armed Forces,
1---- to_ abletR War or Dates 14t1$- I q i(
• Place of Death j6 A v Hospital, Institution or
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City, i ow. or Village OtA-e-e-vi S Street Address a a.S -- v �'1 -
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t Manner of Death l�J Natural Cause 0 Accident 0 Homicide Suicide ri Undetermined ri Pending
W. Circumstances Investigation
ui Medical Certifier Name \ tk- i Jc2►'1►'t-4 Title `
Address o "Cl a fi-t--- 0961S��p '� � D ( k
Death Ceti. .cate Filed CI) District Number Register Number
City, 'own or illage (,t`�W'156tt_( 6L G1 11Li-
LIBurial Date C stery or Crematory
i - 11- ?Ol S tine, VI . L(t'r r
;> ❑Entombment Address
%Cremation QJ( er `--- 0-01 Qt.4..-1--V2S.04 �
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Date Place Removed A
Z Removal and/or Held
and/or Address
F Hold
ta
0 Date Point of
tt Transportation Shipment
d by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
ipi Permit Issued to Registration Number
i< Name of Funeral Home .�j. K( .�,/ n�cra D) i O
Address 1 � ai Y1 „,a_ GIty.AVOL ` tq 1 as
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Name of Funeral Firm Makilh �-"g Disposition or to Whom
1 Remains are Shipped, If Other than Above
Address
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IL Permission is hereby granted to dispose of the human r(' ,
'ns descri•e• ab• - ndicated.
Ni Date Issued la--la_ (et? Registrar of Vital Statistics �f (signature)
District Number ' tofl '1 ou n. 1,
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I certify that the remains of the decedent identified above disposed of in accor. - this permit on:
Z.
ill Date of Disposition Place of Disposition
10
fi (section) (lot number) (grave number)
▪ Name of Sexton or Person in Charge of Premises
2 (please print)
#: Signature Title
(over)
DOH-1555 (02/2004)