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Iverson, David • NEW YORK STATE DEPARTMENT OF HEALTH . .,- • Vital Records Section - 4. Burial - Transit iermit Name First Middle Last Sex ow,i� lve_A-..sv� /I.i.Lc___ Date of Death Age If Veteran of U.S. Armed Forces, 1 if/2a i7 -1 6 War,or Dates - 14 PI. e of Death / Hospital, Institution or own or Village c LCns l('c_ Street Address Le.A, "Ztk )147 WI anner of Death©Natural Cause ❑Accident El Homicide El Suicide ❑Undetermined r ❑Pending ' Circumstances Investigation LA Lu Medical Certifier Name Title fl Icrr Co Ale u.._ • c:,r.,t.Z • Address • 13 40 Si-- PI— 24✓� Gc.���C / hI 1 %24� 1- D Certificate Filed `L District Number U Register Numb iM CV,p, wn or Village L9 e-Ar 'I S ( 3, > »❑Burial Date Cemetery or Crematoryjo • i ❑Entombment / 0 7aoi7 .4cv' c.,, 6c_A-A-AA Address .,I• rr ® /�1c Cremation C A s.�✓r-', / fl1t.,.� 7;r✓e' . . Date Place Removed Z Removal and/or Held 2❑and/or Address N Hold VI O Date Point of ❑Transportation Shipment 6 by Common Destination Carrier [�Disinterment Date Cemetery Address • ❑Reinterment Date Cemetery Address gi • Permit Issued to �� Registration Number Name of Funeral Home + --'e ASM. rr ��;r. ! 4'`- -- -,I.. 0 e, `7-7-‘6-- . I Address Zeret4 A.._ Ave- �or N t ( �ga--)____ Ull Name of Funeral Firm Making Disposition or to Whom 1 Remains are Shipped, If Other than Above . 2 Address • CC ill IL Permission is hereby granted to dispose of the human remains descri Dove s in ' ed. Date Issued 6 /a' //7 Registrar of Vital Statistics / �/. - ( (signature) District Number S 6 o 1 Place .Le-ts--- (It— ) A1e i `j'J(✓( I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: • Z p tii Date of Disposition /ic l� Place of Disposition 1 iV; -► c..�irna'to(i "- • (address) in CC (section) /� (lot number) (grave number) II Name of Sexton or Person in Charge of Premises al 'tti �(r�4,i+�` (plea a print) Signature .11, Title 1eUtlitag. (over) • DOH-1555 (02/2004)