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Emery, Ronald NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First fiddle Lash, Sex /I/.,// / i.✓.'7-h .ter-,e .{4n 11— Date of Death Age If Veteran of U.S. Armed Fore , -J,:..c- Z hs, Zvi/ 7 7 War or Dates .,/� ▪ Place of Death Hospital, Institution or , City, Town or Village C �?.s.e, r Street Address Z,o.,/A,/-� ,� A4 I U-itManner of Death Undetermined Pending I Circumstances Investigation tit Medical Certifier Name // > Title �A©vr Mc h- Al D Address / / / '9� Kwe-re=�' S/ ' /4 A,/ ' /1CP-- Death Certificate Filed District Number Re ist r Number City, Town or Village r,s/1n.,, r •,%> ,R 3 9 0 Burial Date Cemeteror Crematory e/`'// /r'A/L' I//s l (713-1,0)oit.'w d---1 >i ❑Entombment Address . nnCremation� Li A/.a..., Ae..____ Date Pjce Removed Z Removal and/or Held 0❑and/or Address In Hold Date Point of 0 Transportation , Shipment C by Common Destination Carrier Q Disinterment Date Cemetery Address El Reinterment Date Cemetery Address iu 01 Permit Issued to / Registration Number Niiii Name of Funeral Home /! .✓A,,cl �. F..e-,L /...,/ei:., / Al.1t- of/%y Address)/J / 1 / / / yJ %f // L 1-:"4 y[°Ylr J �rPeC dr.✓1%:c /� J /Zen/ Name of Funeral Firm Making Disposition or to Whom t Remains are Shipped, If Other than Above • Address In ` Permission is hereby granted to dispose of the human remains de ribed above as indicated. Date Issued E%/i/ Registrar of Vital Statistics t I (signature) ig District Number,3aZ 3 A Place [} J er I! I certify that the remains of the decedent identified above were isposed of in accordance ith this permit on: Z Ill Date of Disposition Place of Disposition (address) tit Mt I (section) (lot number) (grave number) Name of Sexton or Person in Charge of Premises (please print) • Signature Title (over) DOH-1555 (02/2004)