Conroy, Audrey NEW YORK STATE DEPARTMENT OFHEALTH � A ���8�^��U ~ �7�������^� ����,,~~�^�
Vital Records Section Burial---' Transit--- — - - -
Sex
Name Fir! --Middle Last
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Date* ce
War or Dates
:z Place of Death Hospital, Instituti or
anner of Death Natural Cause Accident 0 Homicide El Suicide o Undetermined r a
Circumstances EI Investigation
Medical Certifier Name Title
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Death Certificate Filed District Number
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Town or ViRaq
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Ln [ ]Transportation by Shipment
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___________________________
Destination
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Permit Issued to
� Registration Number
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Address
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Permission is hereby granted to dispose of the huTemains d cribed abov as indicated.
Date Issued Registrar of Vital Statistics
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I certify that the remains of the decedent identified above were disposed of in accordance with this permit 7:
z Date of Disposition Place of Disposition Itu V 0,?,J C01%C
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Remains are Shipped, If Other than Above
Cl) (section) (kotnumbo (grave number)
�� Name Sexton i Cho, noo `��*"'��
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z (please print)m Signature Title M vft64°
' DOH'1555 (1009) [z1of2 VS-61
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