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Egner, Eugene NEW YORK STATE DEPARTMENT OF HEALTH t Cc- Vital Records Section Burial - Transit Permit Name First Mdle Last Sex L. Date of Death U Age If Veteran of U.TJArmed Forces, t� 3 / x, / a.l 1 War or Dates / - } : Place of Death Hospital, Institution or � Z City, Town F�Villa ��_ 6' r Street Address s%X St. / 3 aManner of Deaf Natural Cause C Accident 0 Homicide 0 Suicide Undetermined FE Pending W Circumstances Investigation W Medical Certifier Name Title a f1 ; ckcc L B' LLL /A. D . Address i Ave-) , g -/- ! 7d�fy 1 3 a Lvt(r /-!vim CO r:k-L k, /�' c^1- ` �g).,- Death Certificate Filed ,/'-' 1 District Number Register Number City, Town or Village C�a r. �'s.1l Date Cemetery or Crematory Burial 3/ ), /aei< r1cv;e_ .... 6a"1-4-Q Address (J N.Cremation ( ,, ,,,,,,,.6,, l . ZDate a / Place Removed O n Removal and/or Held and/or Address Hold Q — Date Point of aj �Transportation Shipment G1 by Common Destination Carrier —Disinterment Date Cemetery Address Reinterment Date Cemetery Address g. Permit Issued to Registration Number M. Name of Funeral Home �_,�S,N,,, 1.,er,t P_,AeI 1.c.. ©Drt-rZ Address tv,„ Ary t, r.4-61. AL l ) a g).2 Name of Funeral Firm Making Disposition or to Whom h" Remains are Shipped, If Other than Above Address W Permission is hereby granted to dispose of the human r ains scribed ov s ' icated. Date Issued 3/a/ /f( Registrar of Vital Statistics . a re) n t Place C_--..� r.ti- N, ( - District Number S l , I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: f'--W Date of Disposition 3-Z3-�( Place of Disposition R, Ott,tt, (WVI-ctI{,t,►`, 2 (address) LU CC (section) mber(lot nu ) (grave number) 0 Name of Sexton or Person in Charg of Premises �exixopr �onnt Z (please print) W Signature c/J Title CREP1/41W1-a'A_ • DOH-1555 (10/89) p. 1 of 2 VS-61