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Spieldenner, Ethel NEW YORK STATE DEPARTMENT OF HEALTH ; # 2 5- Vital Records Section Burial - Transit Permit Name First C G L Mi lle - Last Sex C ;cL� e'l1ei2 _ ' Date of Death / Age If Veteran of U.S Armed Forces, 1 / a' / a 0 r-7 � War or Dates }., Place of Death Hospital. Institution or City, Town,6q lag) T2ff r-. ,o _ Street Address t1 4 Manner oftDeat "©Natural Cause Accident `Homicide Suicide 0 Undetermined — Pending Circumstances Investigation W Medical Certifier Name -- - -- Title 4 �M - -) . .) ati4s0,,\._ PA- Address V.tI rul- 1--I (-1 �cl,� �e. C_-ar..� 1J I Death C ificate Filed /-, District Num� ,er ' Register Number City,/tZwn o Village C __-v r. (1'5 5 Date , Cemetery or Crematory _ Burial I/ G f A 01 G ;,,c v:`.,„ Cie,,,a--i,v/ Address Cremation (?v.(4.4 ^ 4, G7,4,_,„`,,,r Date Place Removed Z — Removal and/or Held '—' and/or Address - Hold O Date Point of Transportation Shipment _ n by Common Destination Carrier Disinterment Date Cemetery Address 7 Reinterment Date Cemetery Address Permit Issued to � Registration Number Name of Funeral Ho�>,Y/ S,,,ucc_.. l cn L /J ,� JJ. 1. 6`1-YK Address ger^^a, Ave t, 0 l y 1 a g.?• -r. Name of Funeral Firm Making Disposition or to Whom' L Remains are Shipped, If Other than Above Address..t.;, .ii..,,, Permission is hereby granted to dispose of the human r ains scribed ov s' icated. gi Date Issued 1/ // 7 Registrar of Vital Statistics a re) District Number �S s 3 Place / - t (v / I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W Date of Disposition 1)S I(7 Place of Disposition ' 1) Cloyhoto c,... M (address) uJ N CC (section) // (lot numb ) (grave number) a. Name of Sexton or Person in Charge Premises e" 4� z (please print) uJ Signature a Title ( T j & DOH-1555 (10/89) p. 1 of 2 VS-61