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Milsom, John . ) a ��/(/ �/ NEW YORK STATE DEPARTMENT OF HEALTH J Vital Records Section Burial - Transit Permit Name _first Middle Last Sex O 1.)Ad-1-y Iin Date of Death Age If Veteran of U.S. Armed Forces, < O — /6 " c/7 /2 War or Dates 19Ga- / 9U6 1-- Place of Death Hospital, Institution Z City, Town or Village 3 L 4 y�001J Street Address (,G US gr p Manner of Death atural Cause Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending Ili ❑ Circumstances Investigation W Medical Certifier Name Title o 5ArA �i fl.v p,.,,0 J D Address a v Fil i r Fi e( five_ Po aci aid( SQL w itA ke_, «eX Death Certificate Filed District Number Register N ber City, Town or Village SC_j -O D /..5 3 Date Ce�ery or C rrC remator❑Burial 'VC //� ��� a-et❑Entombment Address ,Cremation J ea-OS,4oy /V ,Date Place Removed Z Removal and/or Held 9❑and/or Address F- Hold ttt O Date Point of i Transportation Shipment a by Common Destination Carrier ❑Disinterment Date Cemetery Address ❑Reinterment Date Cemetery Address Hili<: Permit Issued to � Registration Number W f t Name of Funeral Home of I._ 71/e_fi) roPern ( dem- co-TV Address al, _, r uo rJ kA ez___ I3_ (. f g 20 Name of Funeral Firm Making Disposition or to Whom • Remains are Shipped, If Other than Above 2 Address It tt !'` Permission is hereby granted to dispose of the human re 'indescribed above as indicated. iig Date Issued ©!— lfrob/9Registrar of Vital Statistics CC j fi.a 1/ . (signature) __, iiiiii District Number /J(,J Place a.4r o'v4) /0 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: l Z tLI Date of Disposition 9i Zt in Place of Disposition f,44/1/,... 4 or;.i.... (address) ILI CA CC (section) / (lot number) (grave number) 0 Name of Sexton or Person in Charge of Pr mises �1r, �1'+1 i it z / (pl se print) 1 Signature i .� Title (kook, (over) DOH-1555 (02/2004)