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Rudd, Jerrad ' ‘IVT 4 i 3q NEW YORK STATE DEPARTMENT OF HEA, Vital Records Section Burial - Tran it Permit M Name First errZ?-� Middle Last �vd� Sex Date of Death Age If Veteran of U.S. Armed Forces, t�21 I S I Z.ol y 8 War or Dates N kc kte of Death Hospital, Institution orTown or Village Gees_ Falls Street Address Ester, Fq h s 4QS i 4Q d �::j: Manner of Deaths Natural Cause �Accident �Homicide Suicide �Undetermined �Pen�ing ii Circumstances Investigation Medical Certifier Name Title c) ic1ets'n 1�.,`Nc\6 V\� Address ad c c - S ee* Glen F'a11S4 N-`) Death Certificate Filed Dist)ict Number Register Number "t Ci y, Town or Village G-\e A\S 5GO 1 J 5 Date Cemetery or Crematory ❑Burial OZ.- 17 - ZO l J) Tine.. V ,e.3 rr ern CA)rUfy Addre . 2,Cremation u 0,4\er- Rek i Dj p eans\oor , N rem q- Date _ i Place RemoVed ZRemoval j and/or Held -- anod/or Address i H�' ld O Date I Point of Q Transportation . Shipment is by Common Destination . Carrier El Disinterment Date Cemetery Address Reinterment Date i Cemetery Address i Permit Issued to _ Registration Number I. Name of Funeral Home RP 6'vr -u.,ani-r_ AWL-- ©J/c39 Ili Address / // L A- .) ,L` ST 0 v62�s ao t2.r A• /2.-d f j/ Name of Funeral Fjrri Making Disposition or to Whom ff. I Remains are Shipped, If Other than Above 411 Address OA Permission is h reb granted to dispose of the human mains described bove as' dica ed. II Date Issued 7 Registrar of Vital Statistics LTA;.7� j (sign ur li District Number 57,a Place i A .l I certify that the remains of the decedent identified above were disposed of in accordance ith this permit on: W Date of Disposition 2..,-]G4 Place of Disposition Di ,v; i e,n vydoc-)' 2 (address) w . Ch CC (section) (lot number) (grave number) 2 Name of Sexton or Person-in Charge of Premises T'c,f Ye)by' . SL,,iif �S P i-- (please print) Signature Title Cre,mc-for - (over) DOH-1555 (9/98)