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NEW YORK STATE DEPARTMENT OF HEAL ilk Vital Records Section Burial - Transit Permit Name First fiddle Last Sex C IO,rC,L. N\a6e_ 1`,1 e}Z F Date of Death Age If Veteran of U.S. Armed Forces, 0 3\ )_a61 io a (® War or Dates N Place of Death ��++ Hospital, Institution or `� C y 'own or Village I�1,e c \\ Street Address ��e RA\1S OSP i Tu Manner of Death Natural Cause Accident Homicide Suicide Undetermined 0 Pending Circumstances Investigation 10 Medical Certifier Name Title ci C=0,,(y\o,OC, \4"\A 0V ?_ M Address Cie. , -Pcx r`(--- S ee-\- G-Lc y V \\S ITV 12 ) iNi Death Certificate Filed District Number ���� r Registere 'umber lai City, Town or Village �7-�v1 �a � S \\ Date Cemetery or Crematory (Burial Oa-.\ 0, laoluz Q;re.._ V; cv:: 0.r-e omo`ko,ry Address < ®Cremation 1D ev�Sb1 C .. , p ZDate I Place Removed fl ❑Removal I and/or Held and/or Address I"- Hold Q Date Point of . N0 Transportation , Shipment 5 by Common Destination • Carrier : Disinterment Date Cemetery Address ElReinterment Date Cemetery Address >'< Permit Issued to _ _ Registration Number < Name of Funeral Home RPtOvC -v,,eay-1--L. ANC- ©i/39 Address /• ilig I/ Li r&f ) IL-`� T , 0oE�2,Sau,z b - / o y • Lig Name of Funeral Fjt'm Making Disposition or to Whom J f - F. Remains are Shipped, If Other than Above 44 Address Uil i `'< Permission is hereby granted to dispose of the human remains describe abo e a ind'g�te ' Date Issued D` o/`2D/.6 Registrar of Vital Statistics i (signature)igl /� / S60/ `Place 6/-et eyo '"'�-` ' District Number `. , /iy ' I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: ill Date of Disposition 2/3 Jj G Place of Disposition volt/ craw '1vX w..•- i (address) iU 0 C (section) (lot number) (grave number) • 0 Name of Sexton or Persorrin Charge of remises uf,s - �tnitill- a. (please print) Signature AV Title ( '1 (over) DOH-1555 (9/98)