Scidmore, Tabatha NEW YORK STAtE DEPARTMENT OF HEALTH' .
Vital Records Section Burial - Transit Permit
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Name First„-- Middle-
..alt Sex--
.. . Date of Death Age -If Veteran of U.S. Armed Forces, '
g War or Dates —
}., Place of__Qath Hospital. Institution or (---- i
Z Cityc--Town p)Village 6-----0 t. 4.. "-- Street Address -... --t#,tk. P., k
Marn-uroDeath r—1
Li Natural Cause 0 Accident 0 Homicide yj Suicide — Undetermined —Pending
Circumstances —Investigation
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LI Medical Certifier Name -t.,, Title
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Address
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Death Certificate Filed -- District,Number Register Number
City Village C. a r, ,ctit— Li4t3
Date Cemetery or Cremator
Li Burial 51151l7 ;4 e 1/,`C...I er---
Address i `.
3 Cremation (.--<1/4.i.e m ) A.)Z.,..., /oft
Date V ' Place Removed
2 Removal n
0 and/or Held
— i i and/or
t-- Address .
o o— H Id ,
O Date Point of
5....) 7 Transportation Shipment
E by Common Destination ..
•
Carrier •
Disinterment Date Cemetery Address.
Reinterment Date Cemetery Address
..i . Permit Issued to ----- --,---: Registration Number
.....- ----
i.1'..::i Name of Funeral Home ._.--1.- c". .,..42re I %.,t_piet-k_ 4--,E• , iv-- 60 ii-ife
Address
7 --.4 e,,,,,,, Av., (---.;f7a--1.... ,k\y
Name of Funeral Firm Making Disposition or to Whom /
.r..", Remains are Shipped, If Other than Above
Address
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';':':::,m Permission is heireby granted to dispose of the human r: - • r scribed ov s"• icated.
A! Date Issued ) 71 '51/7 Registrar of Vital Statistics 1 111 - A.14__/
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District Number 11`-')--C. Place -.-'------0 f , A...+A-- i I
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
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E Date of Disposition 511;117Place of Disposition 'CAL 0,-.1 C:4--r"-
... .. (address)
CC (section) 121 number) (grave number)
o Name of Sexton or Person in Charge 9 .Premises
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(please print)
Li Signature Title IPAAMA
DOH-1555 (10/89) p. 1 of 2 VS•61