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Tremblay Sr, John c t NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First iddle t Swc eS v.1 W 1-i9Ye— 6 3 I rL C� % /%t3Z LH' Date of Death Age if Veteran of U.S. Armed Fore 7/i 1/0 7 0 War or Dates t - Place o *Bath (7)-- City Hos ital,_I stitution or � n 111' Town r Village l. u -A S B Li �t Address S 0 7 A/fd-576� / 1. Mann- o DeathRNatural Cause Q A ident ❑Homicide ❑Suicide ri u Undetermined ©Pending Ili Circumstances Investigation ul Medical Certifier Name Title CI Address DeathDeatkr.,aVicate FiledQ D�ct Number R-Wei-Number Ci To Village U 6 ---,0 U �V-'❑Burial Date Cemetery r Crematory ❑En#ombmen# '7J31 1/7 � J e"" U/6� Address �l remotion � 117A'1°6vL �'C 0�' `,,,` a tin/ A7- Date Place Removed ' ®Removal and/or Held ,i' and/or Address Hold I Date Point of it- [�Transportation Shipment by Common Destination Carrier Disinterment Date Cemetery Address a Renterment -N Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home . &kc r F ne ra. No cy-Y - }}- -v 0 1 l3 D Address t LatONe Aie ri ree+ , Clu eenSb3ry, We ii..i `►or1L I Z b0` Name of Funeral Firm Making Disposition or to Whom 1_- Remains are Shipped, If Other than Above Address itl w Permission is hereby granted to dispose of the human re sins described above as indicated. Date Issued- 1 ? )1 I 71egistrar of Vital Statistics G __Q - 1 - (signature) District Number c (-'-) Place / -� (...D ''`' I certify that the remains of the decedent identified above were disposed of in acco dance th this permit on: � Date of Disposition 'i//7 Place of Disposition //h•ell i �i.-4,0�'"4 7 2: l (address) in (section) (lot number) (grave number) gE Name of Sexton o r o in Charge of Premises i" 1 � (please IIISignature Title (over) DOH-1555 (02/2004)