Singer, Jr. Charles NEW YORK STATE DEPARTMENT OF HEALTH " ., V. Z
Vital Records Section Burial - Transit Permit
Name First l Mid ast _ Se
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is Date of De h Age If Veteran of U.S. Ar ?: F.rces
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_ War or Dates W
14 Place of Death / Hospital,
°' Village (-<'Laj"7---4/- Street Addressutior3r� �144i4 ,. 1� ne
Cit +1 . � or la
�.. Manner of Deathatural Cause 0 Accident Homicide 0 Suicide Undetermine0 Pending
Circumstances Investigation
Medical Certifier 9e77 42/2,4Giric2tle/
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Address
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Death Certificate Filed District Number Register Number
' < City, ow r Village Cher/-efi L o 5-a- J
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❑Burial h 4 j Ao// !/�-�' i ) ( d"--e�, %dd/V< 1 .
rsSk emation Addres r Rc, '''-- - A� l, Y
Date Place Removed
0 ❑Removal and/or Held
�• and/or Address
5 Hold
0 Date Point of
NQ Transportation Shipment
fl by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to I //� Registration Number
'[> Name of Funeral Hom , 1)2✓%,CJ � G��✓ !(� ��,�dtG ®fJ V
gi Adze -e s CAe 'o.(4) 7 / O l/'
"' Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
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Permission is hereby granted to dispose of the hu n remains descri ed above as i icated.
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Date Issued \ - \' U11 Registrar of Vital Sta 4 l�C
ature)
iti District Numb , Place , N<;s., r k -e„-- •
I certify that the remains of the decedent identified above wee disposed of in accordance with this permit on:
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faDate of Disposition 3i )ZyI Z6)C Place of Disposition .t c 0 (en) Ca/0.4i0 t'3vA,
2 (address)
ILI
Cl)
CC (section) b lot num (grave number)
GName of Sexton or P rson in Char.- of Premises t[i r s}or < Jemeq(1-
Z (please print)
94 Signature a �' Title (Qt=tofttet
(over)
DOH-1555 (9/98)