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Stevens, Shirley 1 NEW YORK STATE DEPARTMENT OF HEALTH i - qt i Vital Records Section Burial - Transit Permit Name First C;\cy Middle O Last I Sex Date of Death 3 _ 1 _ ( 1 Ages+ 3 I If Veteran of U.S.Armed Forces, "4 War or Dates P ce of Death os it nstitution or rr[' i ls Z ity Town or Village C(las & `S r dress l kc 1 ail` rm nner of Death RNatural Cause El Accident n Homicide Suicide Undetermined n Pending l y Circumstances Investigation Lu Medical Certifier Name s\jokasjII II _utr Title 4 itritai a 61_ oh v 1,6.1:a ik ,kk Address WO p(,k_f 1(_- S Cil ►s A lic7Nyr vac. 1 I-.th Certificate Filed Ci l I District Number O� llegister Number City Town or Village 4S rk r W :urial Date 3 ' r 1 t gl Cemetery o -+ - - : ❑Entombment Address N ( VI ; .K/1 r./� • Cams k N"] remation Date Place Removed tI-- Removal and/or Held and/or 1 Address Hold 0 Date Point of 0 Transportation Shipment 5 by Common 1 Destination Carrier 1 El Disinterment Date Cemetery Address L Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home X.%ZC_ cL;;-\ ,--rk\ -\rj c\ "� C :11 Address Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above 2 Address CC UI tli Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 3/7/w l'7 Registrar of Vital Statistics W C-LA-4-r\s2_. '\&J (signature) District Number 5120,©, Place 1_ S \\5 p> ,..:::::: _r I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: El Date of Disposition 3)sgjr1 Place of Disposition -Qtnr t.t� ettrnid0P.. 2 (address) ill CC (section) / (tot numb (grave number) O. Name of Sexton or Person in Charge of Premises Pr.) L J�,^itt piease print) bu Signature x.. Title cn klit�/ (over) DOH-1 555 (02/2004)