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Stark, Rita t NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex Rita M.Stark Female Date of Death Age If Veteran of U.S. Armed Forces, 12/12/2017 98 Years War or Dates Place of Death Hospital, Institution or City, Town or Village Granville Village Street Address Indian River Rehabilitation And Nursing Center Manner of Death©Natural Cause ❑Accident ❑Homicide E Suicide ❑Undetermined ❑Pending 4 Circumstances Investigation he Medical Certifier Name Title Sean Bain MD Address 17 Madison St,Granville Village,New York 12832 Death Certificate Filed District Number Register Number City, Town or Village Granville Village 5725 42 1,Burial Date Cemetery or Crematory 12/15/2017 Pine View Creamatory ❑Entombment Address ®Cremation QueensburyTown, New York li Date Place Removed Removal and/or Held and/or Address VHold i Date Point of r- El Transportation Shipment 7 by Common Destination Carrier K.. ❑Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Jilison Funeral Home Inc 00885 Address 46 Williams Street,Whitehall Village,New York 12887 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above 41 Address Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 12/15/2017 Registrar of Vital Statistics WicfardRg6erts fECectronicallySigned. (signature) District Number 5725 Place Granville Village, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: 11 ill Date of Disposition l4111 Place of Disposition ,a�.1 �i+,��or� (address) (section) (lot number) (grave number) Name of Sexton or Person in Charge of Pr mises N^ s„s' MI (pease print) g Si nature Title fkffirtPt (over) DOH-1555 (02/2004)