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Lawrence, Richard
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial .. Transit Permit Name Fir t Middle # Sex oect�.e.e"-e ms Date of Death _— Age If Veteran of U.S. Armed Forces, I— 01 3 I i7 War or Dates t c1 l.� 1L the Place DDeeth yY' i Hospital, Institution or City,.q p or Village j Street Address Manner of Death __ Undetermined ._.Pending � �Natural Cause 0 Accident [�Homicide ©Suicide ® � Circumstances Investigation la Medical Certifier - Name Title Address c cam.._ �-�� Death Certificate Filed m �,� .'._.e.._..__v..... - _---- _ District Number r Registeum ' Ci , art or Villa.- q C� (e; �Buri€�I i Date 3 Cemetery or,Crem►atory {e /!- a (-7 /' ? —P c,,,�� 1.1 a (/12--n-. R—.`-- OEntombment Address Addr n giCremation ' a k cps,_ ,.....A.„,„" +�cA, Q lr-�,,.--- Date �._._ ' Place Removed IRemoval and/or Held 'and/or Address Hold ..�._.__ ._ Date Point of Transportation € Shipment C by Common Destination Carrier 0DisintermentDate Cemetery Address 0 Reinterment Date Cemetery Address a Permit Issued to I Registration Number Name of Funeral Home Address �---- Name of Funeral Firm Making Disposition or to Whom - Remains are Shipped, If Other than Above m 3 K.,_14,m_� w --�� 1 a S. Address nn /f-�\ ..�....__.._.._._.. 41 IL Permission is hereby granted to dispose of the human remains described above as indicated. ' Date Issued /// 2-7 II 7 Registrar of Vital Statistics iL/' 't; .,4 _- l/w Z' (signature) District Number s(0 '� Place 71 (e.-i cr 47C,e_e c___`. I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: #W Date of Disposition Place of Disposition (address) la ;"sectiani (lot number) (grave number) 1:1 Name of Sexton or Person in Charge of Premises 2 tplease,"'mit) , 41 Signature _ _..___.....__.__.._.__._. Title (over) DOH-1555 (02,12004)