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Girard, Sr. Perry -"1 / NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Miii Name .ir .t Middle Wst Sex rEKR �> Rn 1RAR_ . SK, YIACE Date of Death Age If teran of U.S. rmed Focus, '«< N DV , ( ( ,5- 1 ar or Dates 6 s Place of Death Hospital, Institu on or City, n o -Vii je S �A j_j_S Street Address - c-qc -- t\U.- Ft)S? FM t a Manner of Death Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending W. Circumstances Investigation la Medical Certifier Name Title KKm0 L ' RI+A F Address ,S LLS f/DSfrij 00 i'AtRtz s i ) CE i3jd a LOS S u. s) --1r1 I a.?-d ( ei Death Certificate Filed ,., District Number Register Number iR City, Term er Village l-It€. i S - F u c S-40 0/ '15?1/ ❑Burial Date Crematory` , /A�� �� mi❑Entombment 1\10\ic 4( -�( 1 { C Y ( Ei..e) (.(�'.-f-�f�'1hlTZ3 Address Mipifremation a k (i A Fk P C U E-EN QU i-In Al �'()t-,l- Date Place'Rem ved K❑Removal and/or Held 74 and/or Address l=` Hold Date Point of IL r-i Transportation Shipment L by Common Destination lii Carrier Disinterment Date Cemetery Address Q Reinterment Date Cemetery Address Permit Issued to I Registration Number Name of Funeral Home � �, j t i€ L t-E-yvt L ) 1 plc , ©l(p c9-4.t, Eii Address _ 9 0 `T z) fc.�c.4rk S(, LA kC 6 oka. ..) I 1 o� 4 s' Name of Funeral Firm Making Disposition or to Whoa Remains are Shipped, If Other than Above Address • az tip Permission is hereby granted to dispose of the human ains d scribed alcove as indi ated./ Date Issued NA v, o�/f Registrar of Vital Statistics or � -1 " c_ (si nature) District Number r� / Place nKI certify that the remains of the decedent identified above were disposed of in acc this permit on: k /� f Date of Disposition I(-N -)j t( Place of Disposition C�`n e v i e;.J C r-,.✓7u, r7 (address) in iX (section) (lot number) (grave number) Name of Sexton or Person in Charge of Premises wio y l d n t l�e �, ( (please print) f SignatureIn «4.1/ Title C P-c-wtakr r r 15s-4- (over) DOH-1555 (02/2004)