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Therrien, Gene NEW YORK STATE DEPARTMENT OF HEALTH - ) Vital Records Section Burial - Transit Permit Name First Middle Last Sex 6 /vC— t 1 t C 7-7467 2 e/c Ai /1? Date of Death / If Veteran of U.S. Armed Forces, t (S / Age 6 I War or Dates fir; Place o Death Hospital, Institution or W n City, ow r Village 6 N E/+J� Street Address LU 1-i t ?Ti E r/Q ti'1- " a Manner of Death El-Natural Cause 0 Accident 0 Homicide 0 Suicide ri Undetermined El Pending III Circumstances Investigation tu Medical Certifier Name Title JP ill A1,L L i11 1 CA b i2 /At m 0 � a Address tyroi o / tv Icant, n . 2,0 Suit1,e9etiq-nb5 AiY Deaths ificate Filed District Number Register umber City,Crow'n r Village 6 N eA/1— ( © Y i:iiiii0Burial Date 9 s / I Ceme jrry or Crematory Entombmentii t L� Vie Lv Ck Eiyl KI '7' !ti tai l Address U eE-il S 4 iJ i2 Y /?/ �remation OU ilk EW R© - Q Date Place Removed Z Removal and/or Held 2❑and/or Address H Hold f) 0 Date Point of ei Q Transportation Shipment f by Common Destination Carrier Q Disinterment Date Cemetery Address Q Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home6$le, LC-is0 It) F-H • -(-fV C s O d0 T' Address 1' /14 4 T n o cox J 0 _ ) /r / Q ? Name of Funeral Firm Making Disposition or to Whom ` Remains are Shipped, If Other than Above • Address I ILI `` Permission is hereby granted to dispose of the human remains described above as indicated. ill Date Issued 0 /17 I t t Registrar of Vital Statistics csz, (s& \ .C- c L NG (signature) ia District Number 10 `k Place •/ 0 cciv.1 p F 6 H E rv't >..><_:: I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: III• Date of Disposition T1�701 Place of Disposition Pot V V%-) Cf�►..0 1 Vivo-. (address) Ul IA CC (section) /j (lot number) (grave number) C S G Name of Sexton or P rson in Charge f Premises r,tiuI r t+��tt (please print) • Signature Title CP E Ifli COit (over) DOH-1555 (02/2004)