Nicholls, Dorothy NEW YORK STATE DEPARTMENT OFHEALTH ���0�~��D ~ ���������^� �����K��^�
Vit�| RouondoS��k�n ' ��~~" w~~o n . ~~. .~~Uu n-.~. ...Uu
Name First Middle Last Sex
Date of Death
Age If Veteran of U.S. Armed Forces,
War or Dates
Place of Death Hospital, Insti u ion or
-94y,Town or Village Street Address
Manner of Death Natural Cause Accident F� Homicide D Suicide
o Undetermined Fj Pending
W 5� 1-1 Circumstances Investigation
Medical Certifier Name Title
Death Certificate Filed
District Number Register Number
-G4�h,Town er Village
IzCremation Address
Z' Date Place�Fi Red
0 Removal and/or Held
zo
- dress
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Date
Transportation'un_, ^F7~ Shipment
o Common Carrier ..............
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Address
Fl Disinterment --- Cemetery
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Fl Rei�e,menk --e '
Permit Issued to Registration Number
Name of Fun I i
Address
Name of Funeral Firm Making Disposition or to Who
Remains Shipped, If Other than Above
XL
Permission is hereby granted to dispose of the human -mains de n e a ov n Ica ed.
Registrar of Vital Statistics 41FAi =711L" 14M
Date Issued
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ZDate of Disposition 1(b /ILI I Place of Disposition
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2 (address)
Address
on (section) . b*� (grave number)
in Name'�SexmnorPe h ��P �ea A."i�wr ��e��m
zc (please print)
/
uu Signature Title ��e �A�b�
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DOH-1555 A008\ P. 1 Of?
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