johnston, Violet fNEVVYORKSTATEDEPARTMENTOFHEALTH ��Q0�~��� � ���������^� �33^�| K��~�Vha Reoonb So��n �=~~~ °~~� ^ ~ ~~^~~~^~ ~~^ ^^^^Name .1-1, Middle Last
First sex
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Date of Death
If Veteran o Armed Forces,
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of Death
tution
1U City,Town or Village pOr�n 14 "0 k) Street Address
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er NWe Title
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Death Certificate Filed
District Number Register Number
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0 [lRemoval and/or Held
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Point of
cn Fl Transportation by Shipment
Common Carrier - — --.....----------_-----_--_-__-__-.........--...................____________________ ___
Destination" "
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Address
Disinterment --- Cemetery
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Reinterment --- Cemetery-- Address
.... Permit Issued to~� �n�n Number
ir
Name of Funeral F rn
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Address
Remains are Shipped, If Other than Above
Address
ibed above as indicatod.
Permission is hereby granted to dispose of the huma� remains des
Registrar of Vital Statistics
Date Issued 6
District Number Place A
|certify that the remains cf the decedent identified above were disposed of in accor ance with this pormbon:
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DsuoofD\opnoition L /^� > [l P|a000fDiopovkion ���V�� I�rn�Twr/w�
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in (section) (lot number) (grave number)
cc
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(please print) �Name nf Sexton orPerson in Charge of P Ar
m�LIJ
`-~ Signature 14 Th|o
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