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Whitty, Flora NEW YORK STATE DEPARTMENT OF HEALTH It (7 Z- Vital Records Section Burial - Transit—Permit Name Fi addle Last / ,�- Se„_ f/oHl w I //-/ �Q-).o l•� Date of Death Age If Veteran of U.S. Armed Forces, / 0 3 -- 0 C/- 8/G 9` War or Dates /lJd Place of Death —r� Hospital, Institution or - n�� City, Town or Village r )coed.prt el _ Street Address 40-ggyQ_ .+ -- �'/ • Manner of Death Etatural Cause Accident ❑Homicide ❑Suicide ri❑Undetermined ❑Pending tki Circumstances Investigation la Medical Certifier Name Title Q I Q Id_ •e._,_ Iv 6 v Aar t2r ©, 6 Address Death Certificate Filed District Num r Register Number City, Town or Village 7-• � P• ... ❑Burial Date Ce -,tery or Crematory ❑Entombment P 0 /�O • ' '�ted'eV (P�.w�.0.7Q7 Address [6remation r _ o Date P ce Removed/ 9❑Removal and/or Held and/or Address U)i` Hold O Date Point of A0 Transportation Shipment 0 by Common Destination Carrier Disinterment Date Cemetery Address El Reinterment Date Cemetery Address Permit Issued to /' /,- Registration Number Name of Funeral HomaC .Avd- A _G l uber47 Nem1 arf,s-tr. Address �' /— l' — / c71 d —76) Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above • Address ii ,.7 Permission is hereby granted to dispose of the human rema' described ove a ' dicated. in Date Issued e&--67-1,4 Registrar of Vital Statistics I �- \ C` (sign tur ) District Number p 61/ Place I/C��;'�-K>pt /l) ,0 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: ► LEI ��Date of Disposition 3I$ I , Place of Disposition ?wit.) (address) 1a t%l IX (section) (lot number (grave number) el Name of Sexton or Person in Charge of P emises /t),t Z (p ease print) !L Signature I Title � }FA (over) DOH-1555 (02/2004)