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Stone, Louise 0 NEW YORK STATE DEPARTMENT OF HEALTH t - 1 #-i Vital Records Section Burial - Transit Permit <> Name First Middle / Last Sep f O . 5 t_ V, -�o A -f-C._ Cc._ Date of Doh Age If Veteran of U.S. Armed Forces, --kb I° , o 1 ! `f War or Dates P . - of Death Hospital, Institution or .:411i.wn or Village G[eAs f-t l Street Address �..y Lc ,e ,,-}-,R PL..-e. .nner of Death©Natural Cause ❑Accident ❑Homicide ❑Suicide ❑UWdetermined ❑Pending W. Circumstances Investigation tu Medical Certifier Name Title 6 Addres Pat4.-A-v IA 8ver �.e_ �e., � ��) e' 6�"'.cam Il'. ) D-- • Certificate Filed /- ✓/ District Number Register Number •wn or Village 60 LA, T71. i Iv--- sCw 1_ <; ■Burial Date Cemetery or Crematory . ,/1i Aoil Pi)e_V eL.., (!;^-,.i cer 0 Entombment Address ®Cremation a�eeA. . Ne, , 1:,r,,C Date ) 2 Place Removed Z Removal and/or Held 42 ❑and/or � Address f Hold 0 Date Point of ❑Transportation Shipment d by Common Destination Carrier ❑Disinterment Date Cemetery Address ❑Reinterment Date ' Cemetery Address aiiPermit Issued to _--- - Registration Number >' Name of Funeral Home SA-1 orc -r..ket ( H.,,-,, _L . ©o y 72 Address 7 ( 1 e; ,-, AV e �,r. 1 M. I )..x a12— Nil Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above 2 Address III Permission is hereby granted to dispose of the human remains descri ed a ove ind' a 1. Date Issued a / 1 i /,�of I Registrar of Vital Statistics /L2 `it- iL (signature) District Number (0c) Place r / `' aye � �r I certify that the remains of the decedent identied were disposed of in accordance with this permit on: Z p l Date of Disposition f r_g ill?Ott Place of Disposition - ieg OICE CanKchircut., 1 2 (address) tfl CC (section) -) _ (lot number (grave number) Name of Sexton or Person in Charge f Premises / J L L �r=J�'e�� t�1�Glq' ", g,L, (please print)Signature Title (1 Eu -0(� (over) DOH-1555 (02/2004)