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McWain, Roger # IS-1 NEW YORK STATE DEPARTMENT OF HE H Vital Records Section Burial - Transit Permit Ni Name First og� iddle -T \hot Last �'C J 1 Sex Ic.Date of Death Age "If Veteran of U.S. Armed Forces, _ 121 I 1\20 I 5� War or Dates Place of Death nstitution or 2 City, ow or Village (queen u s bry Stdr ) R-q Spec V i 1 Ic,kee_. © Manner of Death co Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending L Circumstances Investigation 14) Medical Certifier Name Title ii:ii Address C 0 a C-1(3, A7 /z?O i.iiiiiDeath Certificate Filed District Number ( Registe Number City, owe or Village 5�c g '� Date Cemetery r Crematory El Burial 1211\12c.).\ P► let,...) Address ECremation DusDA.Ar- V-d,, Q `\�w� , 1W 12ScOy FDate Place Removed . 0 ❑Removal _ i and/or Held -• and/or Address 1. Hold 0 Date • Point of N ❑Transportation Shipment a by Common Destination Carrier >: ❑Disinterment • Date i Cemetery Address .:: ❑Reinterment Date Cemetery Address ?::j Permit Issued to ) / Registration Number Mil Name of Funeral Home _Rt}X6. �,)t,- � ANC" 0113Q _. ' Address / in // L 6-77 " CT• 00 .oS 6 V N' . /2-gli ti ni Name of Funeral Fiem Making Disposition or to Whom il Remains are Shipped, If Other than Above Address iiili.0 Permission is hereby granted to dispose of the human remains described above as indicated. iikiii Date Issued I a- I i a. ( �a ii Registrar of Vital Statistics - A_ k X k & ' IN (signature) imii District Number 59 51 Place Qu e-e 'e 1/j,)/j io I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: i- W Date of Disposition IZ I I) In Place of Disposition gN;If:� g*elc-- 2 (address) uJ C (section) /'(lotnumber (grave number) GName of Sexton or Person in Charge of Premises • G L ..,, �� j (please print) W Signature 6 r Title 41 /htR . (over) DOH-1555 (9/98)