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Potter, Raymond 14 3` NEW YORK STATE DEPARTMENT OF HEALTH o • ` Burial - Transit Permit Vital Records Section Name first Mid Last Se Date of Death Age If Veteran of U.S. Armed Forces, 4 l p2 q— go/ sjq War or Dates /0 0 z Place of Death � Hospital, Institution or ul City Town or Village ,Licit--rA /wc5 t.,A) Street Address s i Manner of Death .Vi:Nat. i :..: Undetermined Pending ILL �� Natural Cause Accident Homicide Suicide Circumstances Investigation Ca . W Medical Certifier Na3p,i, Td Ad ress 14 sG; _do&( )eA iu 0 i--`11,1_...Cam r S3 Death Certificate Filed District Number Register Number City,Town or Village ken- 1`f c.L c0 /4 '/ Date / / L. ` Cem or Crematory El Burial ©a/.0 . ... ::..::: rj u.GUf :,:::. e.i. ,7 AST.-. ::. . Address Cremation Z Date Place Rem ed O: ❑ Removal and/or Held I- and/or Hold :::.::.:.... Address rn 0...:.:. ... ..:...::. b. Date Point of u) 0 Transportation by Shipment p Common Carrier Destination El Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to ? f� 1 Registration Number Name of Funeral Firm C W tb t� A:t K...1/r: _:.-UPer4/ , /1 4— 57? Address ....!;,.. S C- 4 P-0,1_, i--. /Ce- NI' Ic9-c?"7 • t. Name of Funeral Firm Making Disposition or to Whom • Remains are Shipped, If Other than Above Cr. Address tit Permission is h eb granted to dispose of the humayi remains described above as indicated. :> Date Issued 0 ® Age Registrar of Vital Statistics ` 1-4/r._a✓�i-• 6---- -z S (signature) y 4 � i-e?-; • District Number / G` Place NOi`'(i 1. k cLso a I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: t- W Date of Disposition I/1 r 16- Place of Disposition P t �;e.v,/ C�,R,Acc,-}pf y 2 (address) w Z/Z/rb ri (section) (lot number) (grave number) O p Name of Sexton or Person in Charge of Premises V(Jr;%.C,y SD-4;11-5 Z (please print) W Signature Title C f •hCa-Feel"' DOH-1555 (10/89) p. 1 of 2 VS-61