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Hilton Jr., Charles NEW YORK STATE DEPARTMENT OF HEALTI- K Vital Records Section Burial - Transit Permit Nu Name First addle - SehaG�-� = / Alast is Date of D A e If Veteran of U.S. Armed For 9 �' Forces, �� �� �I�� 7 �7 War or Dates f4, Place at s Hospital, Institution City, To or Village�Or/('5 j7 Street Addresstiti �r��� / Manner of Death�yN-�tural Cause ❑Accident ❑Homicide ❑Suicide ri❑Undetermined ri❑Pending '� Circumstances Investigation tu Medical Certifier Nam Title )cI rater 6ae /Vi7 �%�1 Addre s /,,V/r) Death Certificate Filed iD strict Numberlo Re' ister N mber -etty, Town or i lage it corm 5 5111 g , ['Burial Date / C r rema ry ) cd n ['Entombment Address / 4?©/7 1 en ' e !-e GU l 7-c' Q/ f7 via-f-i dress Cremation Qv' --e/I ,_iIL,il/ 7/�G' Date Place Removed Removal and/or Held and/or Address I=► Hold to O Date Point of Transportation Shipment Ls by Common Destination iiig Carrier Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to /� Registration Number Name of Funeral Home$?6 /J)i /7 �/-7� �/�, i1 . G-jry/ ::: Ad re s IIIr��� e c7 -c/©w.7 •/t i %g/ `--- > N me of Funeral Firm Making p Dis osition or to Whom • Remains are Shipped, If Other than Above • Address tr 14). r7 Permission is hereby granted to dispose of the human remains d scribed above s indi d. Date Issued //-- /0/7 Registrar of Vital Statistics e (signature) District Number 1,q..� Place L�7 olvn of ..CC, - a. I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: k D f Date of Disposition Ii/13 11) Place of Disposition j. I , {vr o., (address) W 0 i' (section) lot number) (grave number) ri Name of Sexton or Person in Charge of P mises t ru4+^ ) ,i 2 (ple'alse print) • Signature mow` • Title � m��,� (over) DOH-1555 (02/2004)