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Wittman, John NEW YORK STATE DEPARTMENT OF HEALTH c 3 $' Vital Records Section Burial - Transit Permit Name First Middle Last Sex ohn kI) jfiluz." mzu k, Date of Death Age If Veteran of U.S.Armed Forces, I 1- 1 I- 1 (p if War or Dates Ko re,„,_ 1- P ce of Death /� Hospital, Institutio r /_ 1 ILI Cit , Town or Village l) C 5 ((S Street Address � P�5 vat/3 I45,/Tic. 0 Manner of Death ITI Natural Cause 0 Accident Homicide 0 Suicide Q Undetermined �Pending Circumstances Investigation W Medical Certifier Name Title c GCU'Yi , ki f,�,s— I‘-1,b cti ess S 1 Ca Ay eath Certificate Filed , District Number Register Number :(....c_At,Town or Village 1,G1,S i(S S'(0 0 1 s--79? ❑Burial Date 1 Ce tery or riematory ❑Entombment 11_ f 7 f 6 ) Yl� V) e4.. S I Address Cremation Date 'rPlbce Removed Z El Removal and/or Held 2 and/or Address 1` Hold CA O Date Point of 11.CA[�Transportation Shipment tJ by Common Destinati Carrier Li Disinterment Date Cemetery Address <> 0 Reinterment Date - Cemetery Address Permit Issued to r--- ��G Registration Number Name of Funeral Home �w1�'e Z,1/4 yl Q�� � -l © i j Address i' ehu rc.1 5t LC.ki LUz /-z g Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above aE Address ir US Lt Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 11-I ,rl- //p Registrar of Vital Statistics (A)okiv-._k1 11 (sign ture) District Number Je0 c 1 Place et / o-r-- Gic.ns 1:_,/[.5 :.,.. I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: k I Date of Disposition 1I I lb(1�, Place of Disposition eito„..... ti iaw- aa (address) ill (11 CC (section) i (lot number (grave number) 0 Name of Sexton or Person in Charge of Premises G ns1 kr ,�th4f/r Z. / (please print) iLi Signature IC 'b- Title (P.EMAX (over) DOH-1555 (02/2004)