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Jensen, Beverly NEW YORK STATE DEPARTMENT OF HEALTH �t Vital Records Section Burial - Transit Per Name First Midd1 ,..Last Sex ..,....,, - ` �Date of Death • Age If Veteran of U.S.Armed Forces, ill 61/ (a O ( gg 0 War or Dates" gii Place o I-ath Hospital. Institution or,..— Ci •wn o Village s Street Address L -4 & /� .I • Manner DeathLt. Natural Cause 0cident Homicide [�Suicideri Undetermined ri Pending Circumstances Investigation iii Medical Certifier Name Title • cv-- , n L )5 Lea A M , b Address)it /n 0,n..i It s N• i . l�if a 9 v. t1.�c�5 �-cP E Death rfrficate Filed Dj tricot Number 3 ester Number iie City own�o,Village � y,,,�c� (s`c'�) 3 Date Cemetery or Crematory . ❑Burial II 7 j ,i>i i^Lv cw C+��0. P Address ?: ©Cremation 1� �-e-C�l.$ k AP L,,.s (. s f( . Date ' place Removed Removal - and/or Held 9 1-1 and/or Address Hold 0 Date Point of inQ Transportation Shipment t; by Common Destination Carrier Disinterment Date Cemetery Address [�Renterment Date Cemetery Address <`i Permit Issued to /' Registration Number -< t- H. .. 0 0 `f-�r-C( <;a Name of Funeral Home ��„a rc • Address en i, _ Name of Funeral Firm Making Dispos► i n or to Whom ) 0,, Remains are Shipped, If Other than Above Address W v<:a �``""; Permission is hereby granted to dispose of the human remains described above as indicated. IA Date Issued I Cp! O I) Registrar of Vital Statistics Q , Oz lli� (si nature) i • Place f 0 C " District Numbeh(Q��l ��.5� _ r I certify that the remains of the decedent identified at3ove were disposed of in aces danc: with this permit on: i1 PIN '`W Date of Disposition ZIi h( Place of Disposition V 1! *Mae(wi 2 (address) w . • ca cc (section) 4 (lot n tuber) (grave number) QName of Sexton or Person in Charge f Premises (i i +r Jt o�� I (please print) Signatu?e Title (2 r r c (, (over) DOH-1555 (9/98)