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Jasmin, Earl 4 , # , (3 NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First CC Middle Last T Sex V\ l_..U.r 1 La...3YtrrCL X kv1 NO Date of Death Age I If Veteran of U.S. Armed Forces, 08 11-1 1Lo\k.0 (13 War or NIA f4 Place of Death Hospital, nstitutio r ' A City, Town or Village .nab-o c SQC,'nt)S Street Address J W ESL Manner of Death atural Cause El Accident Homicide 0 Suicide Undetermined Pending Circumstances Investigation Medical Certifier Name f,) Title n ,sb Address / ( N, iE `' Death Certificate Filed District Numbed Re ister N mber City, Town or Village S cvccoro v. ;nc 1 S 0 L 9 Date Cemetery o rematory ❑Burial ©b (Z71 2-0\k-9 cp MR. V i Cw_ -me �-'y Address 1 : : Cremationn �nsy�u r y / IQ i I Z$p Date Place Removed . Removal i and/or Held and/or Address = Hold 0 0 Date I Point of tch ❑Transportation Shipment G by Common Destination Carrier Disinterment Date Cemetery Address Reinterment Date Cemetery Address ?H LiPermit Issued to Registration Number 11. Name of Funeral Home , I ._<6- ,)i�i Mici 0030 Address / d. If 1-/a- L-T7Z�'" Si 0 o oS a i3. ( `i /2. y Name of Funeral F� Making Disposition or to Whom Remains are Shipped, If Other than Above Address IX Permission is hereby granted to dispose of the human remaii de _rand abet ndicate llig Date Issued 9gJ21)i(9 Registrar of Vital Statistics (si nature) District Number 1-601 Place Ntralt9a / I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W Date of Disposition $(3iii4 Place of Disposition ?iv.L .' C c M (address) U) C (section) //lot number) (grave number) GName of Sexton or Person in Charge of Premises GLn`number),_ `� ,/` (please print) W Signature Gt �� Title aEMi170e_ (over) DOH-1555 (9/98)