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Richards, Joan s. . f NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section T 1 Burial - Transit Permit Name First (7 Middle Sew Vic? �nl � 4�� Date of De th Age If Veteran of U.S. Armed Forces, ,711,// �3 War or Dates i Place o Deat Hospital, Institution or WCity, Town or Village Street Address Manner of Death©Natural Cause ❑Accident ❑Homicide ❑Suicide El❑Undetermined ❑Pending ILICircumstances Investigation tu Medical Certifier Name Title Address Death Certificate Filed Distr<ct Number i— Register Number City, Town or Village ,,C L,2.4z11% 474..)n� / S ❑Burial Date Ce tery or Cremate / c,/ ❑Entombment / 7/1' 7 "`.)�y,Z,kj sec 1��/ Addr ®Cremation (/G G`/-V5A//1/ Ay- / Date Place Removed Z Removal and/or Held 2L-1 and/or Address TI Hold Date Point of 5 0 Transportation Shipment el by Common Destination Carrier Disinterment Date Cemetery Address Q Reinterment Date Cemetery Address Permit Issued to l4'71' Registration Number Name of Funeral Home alif,CA! ,e_X-- wu,5?" /7 pDS/9 Address �'—� ife;0/1/ /L,Oi; /V . /-?870 me of Funeral Firm Making Disposition or to Whom } Remains are Shipped, If Other than Above 2 Address Cr Ili __ s Permission is hereby granted to dispose of the human re ins d scribed above as indicated. Date Issued /ii,/f Registrar of Vital Statistics % Z (signature) District Number-,1 Place &11 yj � �Q t hi) " I certify that the remains of the decedent identified abo were disposed of in accordance with this permit on: p Place of Disposition 'P U�, ` OD ex... I� Date of Disposition bill �� p ,n� 2 (address) ILI CC (section) (lot number) (grave number) fa Name of Sexton or Person in Charge f Premises /1^{s —8'►'I�tl z (pl ase print) Signature Title f rn IVZ- (over) DOH-1555 (02/2004)