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Mehalick, Ute NEW YORK STATE DEPARTMENT OF HEALTH f > �� ,Vim Records Section Burial - Transit Per it Name First tt.J, Middle )`a .e f�, MK 'Date of Death Age If Veteran of,U.S.Armed Forces, 71idy,26/7 7(0 War or Dates p• Place of Death Hospital, Institution or :. City,Town or Vdlage Oil-U.1 NS a�.y Street Address - LA3 14- Manner of Deathg!Natural Cause 0 Accident ❑Homiade El Suicide 0 Circumstances4-4 Investigation ' ` Medical Certifier Name Title _- ©j'L L A/ _CO o c.D /1 , Address Fi 4) ( �-, . — - OS1 y Death.Certificate Filed District Number Reegis—th vr Number C. Town or 1t, .,, : C,t -2 i;IS 6 Y S t.5 . . - 8'1 Qeurlau 7//Z/2.617 Cemetery . Crematory e/7141"e A-ga i j]Entombment Adds s Dabs Place Removed ./ 1-1 Held Removal and/or f and/or Address L: Hold �# Date Point of Q Transportation Shipment by Common Destination Carrier S Date Cemetery Address ;4 Q Disinterment Q Renterment Date Cemetery Address k `_ Permit Issued to Registration Number Name of Funeral Home - $, ),z.c V I 19 2 • Address .6' eJ 15-1 I e.(s- i s lc y i. .2ci-0) rta Name of Funeral Finn Making Disposition or to Whom Remains are Shipped, If Other than Above AdAddressK. I rze Permission is hereby granted to dispose of the human remains described above as indicated. x Date issued `1-,2. -;Di 1 Registrar of Vital Statistics --Q'o-Ak -4.. 4 4..)\ (signature) District Number 5l051 Place <- V ce6Sbo/ I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition l lit!f) Place of Disposition • Paetl'a rM'n4ftlr ._ (ate) (sermon) 11(tct number) S (grave number) Name of Sexton or Person in Charge ofpremises ru e- G I4* 4 -'Z Title Signature L -y t}'" ' (over) • DOH-1555(02/ 004/2 )