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Olmstead, Debbie NEW YORK STATE DEPARTMENT OF HEALTH V Vital Records Section Burial - Transit Peimit Name Firs(1 i Middle Last Sex b T. - L r , ` p,6 Date of Death Age If Veteran of U.S. Armed Forces, ) -Q,J-7in i'7 (' � War or Dates gPlace • r-ath Hospital, Institution or (.\ j� _Ci , TJno Village N r�r�� Street Address �j(p��J I' �-E{cv N AEt,.) ,nip Man - o Death atural Cause C�Accident �Homicide �Suicide Undetermined ❑APending Circumstances Investigation id Medical Certifier Name ` , Title el Address P O 504 `"l ioP, 1. Rit ak ia NI 17-`1 c Deat ificate Filed District Number Register Number City Tow r Village I�.wCt Vila. )5 61 _ 4- a.c) i1 (]Burial Date C mete or Cre tory ptombnent 12- i2- 1`7 , t ►�V i�(,i) V-ri' rt Ri Address }.emation 21 Q i/'PrKnz ly- C.)wF t urz4 )/ 1 G 11 Date Place Removed' • Removal and/or Held ▪ and/or Address Hold Date Point of a Transportation Shipment i by Common Destination Carrier _ 0 Disinterment Date Cemetery Address iii! Q Reinterment Date Cemetery Address Permit Issued to ��hh (� Registration Number »> Name of Funeral Home►`I��j,V`in,� rVrJFJZArL l �ot�1i 01 0'7 Address ►? 19NI t �.1- . , �� • e Fa .,e /U,/ Cam©; <` Name of Funeral Firm Making Disposition or to Whom tt Remains are Shipped, If Other than Above 2 Address it t W. Permission is hereby granted to dispose of the human rem ns describe ove s indicated. Date Issued 12 1 2.017 Registrar of Vital Statistics at, (signature) >' District Number /izj Place ('V J2- AJCiD I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: k p Date of Disposition al it iin Place of Disposition i� - 1 lel,' ig (section) gg (lot n mber) (grave number) g• Name of Sexton or Person in Charge of Premis s _ I t v-Alt 2 )(please print) Signature Title I / MINI-- (over) DOH-1555 (02/2004)