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Senecal, Virginia NEW YORK STATE DEPARTMENT OF HEALTH Tr 3 76 Vital Records Section K Burial - Transit Permit Name First Middle Last Spx, V1 n,� �' _se�e_c , fi Date of Death Age If Veteran of U.S. Armed Forces, 141 K 41 " .oi 6 �1 War or Dates 1- Place o D-ath Hospital, Institution or Z CitA own .r llage Me, (' y Street Address S I L� !. 0 M.-•- • Death Natural Cause Accident Homicide Suicide Undelbr ed 0 Pending W. ® Circumstances Investigation la Medical Certifier Name Title Address �--� v i, . p�f� Vt. 64 -{-.moo 1 I t Death ificate Filed A I District Number Register Number Ci ,Lwn o Village r ,r -- - 4-1-5-6 t t Burial Date Cemetery or Cremato []Entombment /t3' s/ „ d_ V`;G Address A Al Cremation C.JLGC'^ 4 b �r° -! Date P A Place Removed Z❑Removal I and/or Held Cg and/or Address N Hold 0 Date • Point of tij Transportation Shipment L by Common Destination Carrier Q Disinterment Date Cemetery Address 0 Reinterment Date Cemetery Address iig Permit Issued to .„,-- Registration Number Name of Funeral Home ., s.,r,r c 1—H ©u '-4eP Address 74 L or I-1 Ce'a :: Name of Funeral Firm Making Dispositi n or to Whom Remains are Shipped, If Other than Above. a Address 1C 'U Permission is hereby granted to dispose of the human re descri a ve as indicated. ii:!;ii Date Issued°,.,-/2O120 Registrar of Vital Statistics (sig ure) District Number d - Place aS) e. fld/ds ed,/ Moyeao it ?/ Ir- I certify that the remains of the decedent identified bove were disposed of in accordance with this permit on: Z til Date of Disposition 51 13//L Place of Disposition eetic ,/ a -.,- . 2 (address) fl CO U. (section) (lot numb} (grave number) ci Name of Sexton or Person in Cha ge of Premises [ 4ht se J\ z /�j (p a print) Signature (.0 Title a►'' i019 (over) DOH-1555 (02/2004)