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NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
sc�,,4,P_ p J ie4,0,e/�
Date of Deat Age If Veteran of U.S. Armed Forces,
07- 30 - go/( 76 War or Dates ,J
I Place of Death Hospital, Institution or
w City, Town or Village ) ei..1 et, r c
0 Manner of Death 11'4, Natural Cause 0 Accident D Homicide 0 Suicide El Undetermined riPending
illCircumstances Investigation
u Medical Certifierame ,� Title
>t f,l^<4Av`ci dy G-4 vof4 /✓/1)
Address
is ,t wiNc*_. -noA . e4 -re -cv+3a 1.21.5-3
Death Certificate Filed District Numbe�r/' Register Number
City, Town or Village 1)66+nb1 eYL<,d t,_ /.5 G / 347
OBurial Date C metery or Crematory
OF- of- ?-ef f'ii w1e& ?re-r11A1csrv'
Entombment Address r-?
IICremation Vl t f ..N S bur.- /Ur •
Date ! Place Removed
Z❑Removal and/or Held
and/or Address
i'= Hold
CA
0 Date Point of
Eti
Q Transportation Shipment
C3 by Common Destination
v. Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home E4A,,k L. (&L I". Few{.i-t 1 H. d 0 S(1
:„i,.- Address S4 ra-a0 L, p. l77. / 7C)
Name of Funeral Firm Making Disposition or to Whom
}.. Remains are Shipped, If Other than Above
Address
Z
la
m Permission is hereby granted to dispose of the human remai s escribed abov s i ' ated.
Date Issued(Y i—gd/4* Registrar of Vital Statistics
(signature
District Number IS'G t! Place / j CC,„ P r test, / ,
::: I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI Date of Disposition gNM/` Place of Disposition �MOl d (1erro r --
1 (address),
i)
III (section) //(lot number) C (grave number)
Name of Sexton or Person in Charge of Premises r ��t ✓Eh
(pl se print)
Li, Signature 11� 4 TitleM
(over)
DOH-1555 (02/2004)