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Shippee, Barbara , NEW YORK STATE DEPARTMENT OF HEALTH ti Zl Vital Records Section Burial - Transit Permit Name First : Middle — Last ci Sew Date of Death Age If Veteran of U.S. Armed Fordds,' t/. 7/ ),oil 71 War or Dates l Place of Death Hospital, Institution or Z. Cit , Town)or Village D .i Street Address 0 )-- SI"` o e e Q`'k- 14 1 Man of Death©Natural C ❑Accident El Homicide El Suicide ❑Undet&mined ❑Pending U Circumstances Investigation W Medical Certifier Name Title 0 r .S, fi;• /11 D . pil Address ,, Death ificate Filed District Number Register Number City, Tgwn Village D `1 5 `1 d L la❑Burial Date Cemetery or Crematory / ['Entombment Address /& / `°`\ �,so v;e.� U'c,,,,-idt Address <<`aCremation v.L -e- s ki...% /lac�, 'rat.4 Date L' Place Removed 6 El❑Removal and/or Held v. and/or Address 0 Hold 0 Date Point of ft❑Transportation Shipment a by Common Destination Carrier ❑Disinterment Date Cemetery Address ❑Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home e A s.M,rc.. ,‘e r� ( •{--f'-.M/ 6,a 4-f-4-z_ Address Name of Funeral Firm Making Disposition or to Whom 1 Remains are Shipped, If Other than Above 2 Address CC W 11 Permission is hereby granted to dispose of the human r main descri ed above as in•' - - • 11 '> Date Issued a�' ^ 1 Registrar of Vital Statistics (P‘_kst (S' M' (sign ture) District Number � Place A i I certify that the remains of the decedent identified above were disp sed of in accordance with this permit on: ttij Date of Disposition 1'I i Place of Disposition PIN ,../ l.ivmS f 6five., W (address) CC (section) (lot nu er � ) (grave number) Name of Sexton or P r on in Charge o remises 1 h r+,t cr. .)eANAF , (please print) Signature i Title CV 4=AI OIL- : (over) DOH-1555 (02/2004)