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NEW YORK STATE DEPARTMENT OF HEALTH• Burial - Transit Permit it
Vital Records Section
Name Firs . —) ?Se Last Sex
Date of Death / Age If Veteran of U.S. Armed Forces,
11 /- / aoi7 �-1 War or Dates
Place of Death Hospital Institution or � pp
:4 City, Town �ilia� Co I'. Street Address LN'K M�•^ �r4_
tManner of Deat�i 0 Natural Cause NAccident 0 Homicide 0 Suicide � Undetermined H Pending
Circumstances Investigation
Medical Certifier Name n^ Titllg
/ - Iiv1,,, L " . �,v;r."Gcv r�'l
Address , t ty
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)-( hrvI ��rr1 N I ) 646Death Certificate Filed District !Number ) Register NumberCity. Town or Village .. S.
Date ^� y . emetery or Cremat �/�_Burial , if / °'c" - / o/7 %ke_ viL w Imo;,• t�-io
Address 1 •
Q Cremation i , I L/
Dale �' Place Removed
O Removal and/or Held
H and/or Address
v7 Hold • •
O Date Point of
Transportation Shipment _
E by Common Destination
Carrier
Disinterment Date Cemetery Address.
C Reinterment Date Cemetery Address
Permit Issued to Registration Number
+., Name of Funeral Home e_A S,v„..,,c 7 H1 -4. 4 0 Lierc
Address y
7 er s-�- Ave; l�f. 0l ) -s a L---
> Name of Funeral Firm Making Disposition or to Whom
L" Remains are Shipped, If Other than Above
Address
ti Permission Is hereby granted to dispose of the human r: • = • :scribed ov- - •icated.
Date Issued VD/ //7 Registrar of Vital Statistics
9 l.U, - 4
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1 �
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District Number 1-fS-53 Place �r; _ /v1 e—�' / nr71 I
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
wDate of Disposition /I/13)11 Place of Disposition lX,11...- ('„r.-#f e..__
., (address)
uw
to
cC (section) lot number) (grave number)
Q. 4 Name of Sexton or Person in Charge of Premises /'k ; ->t-kwr1
Z (please print) t
W Signature Title ibit
00H•1555 (10/89) p..1 of 2 vs.