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Diduch, Peter .S CO NEW YORK STATE DEPARTMENT OF HEALTH `at Vital Records Section Burial - Transit Permit Name irs addle Last Sex 'l C- h©rA S VI a J(JA (VIA t _ Date of Deatlio (D 1 I r Age !� If Veteran of U.S. Armed Forces, 4 ( War or Dates }- Place • seath l ( Hospital, Institution or ii City • i •r Village ` � Street Address a Man of Death❑Natural Cause ❑Accident ❑Homicide laSuicide ❑Undetermined ❑Pending ua Circumstances Investigation ta Medical Certifier Name itle EJ1X� ('_ RZ' k)s ,-•,1' -- FO(dif)L, -•s 1 ! - i AV? 1 � f Death+*`• icate Fi ed �; District Numbed sz, Register Number City, ow •r Village (ti , V in❑Buria Date I 1 /i C rr n 'r_or.yr em ry ���� ❑Entombment Address �/A /l i a itity ;;;Cremation O(?� i& ��� 5 Date Place Removed 1 t❑Removal and/or Held and/or Address M= Hold to Date Point of aEl Transportation Shipment Et by Common Destination Carrier ❑Disinterment Date Cemetery Address ❑Reinterment Date Cemetery Address Permit Issued to Re i�trai Number Name of Funeral Home � (A/VIA.- Ib t t Address II 1Z W 11/1/410 5- ilL- W 1300q Name of Funeral Firm Making Disposition or to Whom • Remains are Shipped, If Other than Above • Address Lu Permission is h eb granted to dispose of the human re s describe ab e s indicated. il Date Issued 1(� Ut t ( Registrar of Vital Statistics ea/ 1 (signature) iiiiN District Number 7 Place ' /060,1 d P fitly'�-- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: III• Date of Disposition id /,3 hi Place of Disposition Pin.iticca Clow-4-tor 1,0%- 2 (address) ill in CC (section) A F (lot number) (grave number) Name of Sexton or Person i Charge of P emises r+>} r 3t"16- Z ( lease print) ILI Signature Title Cttiz rt-Td- (over) DOH-1555 (02/2004)