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Wood, Helen NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - 'transit Permit Name First Middle Last Sex Date of Death Age .. If Veteran of U.S. Armed Forces, ©Cr: O/,, c O/le 9ay,es War or Dates //4` 1- Place of Death Hospital, Institution or LT,?, W City, Town or illag 6RiQA/1//i LE Street Address2A/O/ j/ OF/t4 Q R.E /,�f,� BANi.t'/4,6- W▪ Manner of Deat 2 Natural Cause Accident 0 Homicide Suicide 0 Undetermined El Pending Circumstances Investigation W Medical Certifier Name Title 7-16m4s /��N©oR/9 mn. Address SNDii,l,v R/o'ERAteas /G VTR efeR64W4-1 A/;Y icpvcr — Death Certificate Filed District 1�lumber `� Register Number City, Town or illage 4,916///I .. --- --4---- . 7 (Burial Date �j Cemetery or Crematory ['Entombment /D—Oy—..2o/ ' "✓Cv/Elv Ca0'B7l�Toet iri Address Cremation 4W,e.EA/S)eilat,/ y}/ 1.1c�Ql, Date �, Place Removed ❑Removal and/or Held p° and/or Address En Hold 0 Date Point of NQ Transportation Shipment Et by Common Destination Carrier Q Disinterment Date Cemetery Address Q Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home `jf,09-.S7p// FG/A/�iq 9L I/0776- 0/// 7 Address /c )6 e'Rcr-6S 7 FG T i /,/y /1Yy /a? d. ? Name of Funeral Firm Making Disposition or to Whom' 1- Remains are Shipped, If Other than Above 2 Address 0 ILI fl` Permission is hereby granted to dispose of the human remains iiiiiiiiiie;• i.o 'lig icated. Date Issued /Q O4, 8/Registrar of Vital Statistics ffirIf WIG (signature) District Number 5--,2,s' Place U .e.._ szja_,V__,g/2iea,„7-y.e/--e:eegz., 2/3.11. '/ I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z (? W Date of Disposition jot S/j Place of Disposition gnt1At� (+ 6trYnere)(t -- 2 (address) ILI LO I. (section) dr;i (lot numb (grave number) p Name of Sexton or Person in Charge of Premises 11I f Z �/n lease print) Signature ' Title C d1 -- (over) DOH-1555 (02/2004)