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Jowaiszas, Virginia NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Ni Name First Middle Last— S� Vie ice, M 3rsc,J� szuS� 1 `M"(...., Date of Death Age If Veteran of U.S. Armed Forces, 1) /4 2/i ( 76 War or Dates E a of Death Hospital, Institution or �i own or Village LeA s fi�1 1s Street Address anner of Death Q Natural Cause Accident �Homicide 0 Suicide El Undetermined Pending W. Circumstances Investigation tu Medical Certifier Namc , Title 10�-r�,co VO LA IN se_ ti D . Addr�ssat Ttir� St.l ��.r-i 4,45 N it � � gaI D th Certificate Filed/ 1lss�� District Number Register Number ,r it own or Village c• Lc.4; -I- (�f E ,47 Burial Date Cemet or Crematory �,, yL it (A�� /?J f 1 ;1 .M l.4--r ❑Entombment Address c c� V` Cremation 0-ke-c�).5.-" pc� j ,'L Date j / Place Removed Z Removal and/or Held 9 I—land/or �; Address ti) Hold C Date Point of ti ❑Transportation Shipment O by Common Destination Mii Carrier Q Disinterment Date Cemetery Address Q Reinterment Date Cemetery Address qii Permit Issued to _ Registration Number Name of Funeral Home t��.�..). �,:,�. ( -),.„,... O©`f`t'L Address 7 5 herAA.-• Ave /. � M. '1 J I )BzZ iii Name of Funeral Firm Making Disposition or to Whom / 14 Remains are Shipped, If Other than Above ';; Address t: Permission is he eby ranted to dispose of the human remains described above as indicated. liiiiiii Date Issued '1,.S' 9 i Registrar of Vital Statistics iL,O .. (si District Number 360 / Place 6\zv,a .,\\s N y >::<: I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: 1I Date of Disposition '4/ 4!II Place of Disposition gm,LS.r (MAI brw.,'. 2 (address) ILI CO Cr (section) 4 (lot SAVE (grave number) f•S' Name of Sexton or Pers n in Charge o Premises 1 S[4A4tt 2 ghlk (pi se print) • Signature Title CEEgn y( (over) DOH-1555 (02/2004)