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Potvin, Kelleen , . / 71 NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial _ Transit Permit Name First i �le Po Tv �✓ ✓j LPL t= ' /—t_iliitt t Date of Death/I lam©le AgeIf Veteran of U.S.Armed Forces, / War or Dates Z ce of Death i Hospital,Institution or ./ own or Village t om' — �!}tLS Street Address 6-h'F--ZS f'�u-$ igi P v AZ_ p V anner of Death[Natural Cause 0 Accident Homicide El Suicide El Undetermined �Pending W Circumstances Investigation I Medical Certifier Name Title 4 �f� �-L f� � �1L,/ Address `0 ., s7"-- 6-a(eAL Aix / ) D.=, Certificate Flied �/ District Number— R�sterl4 r ' �► own or Village 66C JS t 4S �7 C� f Burial Date / / o aneg- eieri7,9 Tz6�ci ['Entombment Address cremation (9` i'.6@ ,e4 0Ic 6wev ,0 y J2d1 9 Date Place Removed Removal and/or Held ana O and/or Address N Hold 0 Date Point of PEi Transportation Shipment Q by Common Destination Carrier 0 Disinterment Date Cemetery Address El Reinterment Date Cemetery Address Permit Issued to Registration Num r . Name of Funeral Home q(4-bi--tT Fr— "'"- . 4oc} 2/4'=� Address 63/9-seR15/J 6—Afc-Aii --AM-Z-_-S ioy /an / Name of Funeral Firm Making Disposition or to Whom Remains are Ship ped,If Other than Above E Address 1 W Permission is hereby granted to dispose of the human remains described above as Indicated. f. Date Issued 3 /'2-c-// 1 6 Registrar of Vital Statistics LALA-A-re4— .,. (signature) District Number EL;0 J Place 6 CQ1vv.S Fe( 11 S , Ni 7 31 IT- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: ILI Date of Disposition 31 t51)L Place of Disposition et a cv+ C,w„ st.„ , W (address) U) CC (section) �/(lot nwnberr` (grave number) a Name of Sexton or Person in Charge of Premises ��,i T �.{J����r� Z r (l s print) Signaturetil �,, Title art (over) DOH-1555(02/2004)