Ridout, Francis NEW YORK STATE DEPARTMENT OF HEALTH +_ ,�
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Vital Records Section Burial - Transit Permit
Name First , Middle Last Sex
Date of Death Age If Veteran of U.S. Armed'Forces,
APR ,L J6 ole (( 7A War or Dates Kb }}Nk
1 Place of Death ' Hospital, Institution or
City,Tewii er Village 6:rf,6/=s - 3L-LS Street Address 6-GE 0S -R‘.t.4.-,S {irls'?l.7711.._
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Manner of Death a Natural Cause El Accident ci Homicide El Suicide Undetermined El Pending
Circumstances Investigation
0.
ta Medical Certifier Name Title
Address
`Ara it J1-() GE/US 44U-S) 'Yl / /2ga/
: Death Certificate Filed District Number Register/*Number
City, Tert w orViildye C-tE S S�O j / /
> OBurial Date /� ry-er-Crematory
i < O Entombment �P�`/` /�� c // '6 /Z%G /Ff�J 1 rn47Z1
Address
>< ' Cremation 4/ (?lam,*/5R-- I2Y L`—E/()S-rp�V -U l J c 5
�� Date -Plac Removed
El Removal and/or Held
"R and/or Address
ft)�=" Hold
0 Date Point of
IW
O Transportation Shipment
Ct by Common Destination
Carrier
O Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address _�
Permit Issued to Registration Number
Name of Funeral Home -j d ,, EAL 7 7 J �jo C, ,SG
Address
Name of Funeral Firm Making Disposition or to Xe- 66-eizir-c) -IP LAWhom � /
9-6
Remains are Shipped, If Other than Above U
M. Address
1E
40-
C`:` Permission is her by ranted to dispose of the human remains describec�.above as incl.
Mi Date Issued Registrar of Vital Statistics p_4241
(Si g ature)
District Number 676-c)J Place `4&)7 „/f:,����i
I certify that the remains of the decedent identified above w re disposed of in accordance w this permit on:
ILI 1,
• Date of Disposition N•IS-I�t 'Place of Disposition •Pmr U,e J (n r.c{or 14".
2 (address)
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VI
1X (section) ii, (lot numbe (grave number)
o
12 Name of Sexton of P son in Charg of Premises r }corj'
2 / , (please print)
Si nature '� Title F-M* i)'0'
(over)
DOH-1555 (02/2004)