LaPlanche, Terry NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section urinal _ Transit Permit
_ ! Name First __ Middle Last
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a,Pl n -e 1 Sex
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Date of Death I Age I If Veteran of U.S.Armed Forces,
au 1 (CI 17ffl , Leo I �t�
War or Dates
t Place of Death I H " 1, Institution or
27 III City Town or �t (,�,k I treat Addre 35 Ned& S4-e+
E Manner of Death Natural Cause Accident 0 Homi Suicide 7 Undetermined n Pending
Circumstances Investigation
uj Medical Certifier Name Title
50 6 road eS dire e t lnl -er. /vim Yo>,- 1).. 5
Death Certific.t lied _ District Number �a Register Number
•> City,Town o Vv i 1--e V100 I 1 5--7 C)
Burial i Date C etery or ,remat
[]Entombment q' 7
5I 26 l 3 1"int t i'r'� t�re�YlQ�!7�
Addr s l
; : Cremation (fit,(&k ( �� kfu b Jet.)am) IorL i-2-so'clig
Date f Place Removed I
Removal I and/or Held
�, and/or ; Address
H Hold
0 Date Point of
cL Transportation Shipment
- by Common Destination
Carrier
(Disinterment Date Cemetery Address
E Reinterment I Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home � `ZE i1 L,` AA HOC 1
Address ` C�} ,}C
t
Name of Funeral Firm Making Disposition or to Whom
EF Remains are Shipped, If Other than Above
Z Address
M
Ill
Permission is hereby granted to dispose of the human re, ains described above as indicated.
Date Issued 4/a�/J7 Registrar of Vital StatisticsIlk ' I Q
r ' (signature)
r57o70'
District Number Place 1, 1 ,, ha/1 �de� l d Y/<
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` I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Ed Date of Disposition Al/74 in Place of Disposition tVt i w Cr tf or-f orFt,.%,
(address)
i
(section) (lot numbe (grave number)
a 1� 6/Name of Sexton or Person in Charg f Premises �a asllt
Z (plese print)
f Signature !r' Title MKll�'l it
(over)
-
DOH-1555 (0212004)