Banta, Patrick -
NEW YORK STATE DEPARTMENT OF HEALTH Cl�
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
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Date of Death Age / If Veteran of U.S. Armed Forces,
,-!).2. /22/ W/l 1/ War or Dates („j t,,/ j
1- Place of Death Hospital, Institution or
hZ City, ow or Village/!/ t,✓i/A � Street Address rA.74/L^/ 3Trk/ '1 j /-I_
0 Manner of Death atural Cause Ei Accident 0 Homicide Suicide 17 Undetermined 0 Pending
itil Circumstances Investigation
W Medical Certifier Name Title
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Address
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Death Certificate Filed Distric,uspb�r Register Number
City ow or Village/VE,+ I-/ATOP-fj ` C(-'L
0 Burial Date Cemetery or Crematory
az 1oi/2O// J,�NE vixi,✓ egpivTraPii
['Entombment Address
emation q k4FE,J3 a - N',
Date Place Removed
❑Removal and/or Held
and/or Address
H Hold
Date Point of
%0 Transportation Shipment
0 by Common Destination
iiiii Carrier
El Disinterment Date Cemetery Address
-
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home MILIFK ruAlEg41 /40 _ 7j22--Z--
<' Address
35 Li MA,,) .31-, rO P7X 7✓6'l /pi DMA/ G(1,k—,E. N`/ /2gt-12-
• Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
L 1
n^` Permission is hereby granted to dispose of the hum e ins escribed ve as indicated.Date Issued / Registrar of Vital Statistics • t�� 402.7o
atur )
giiii District Numbe()&&-c / Place 1 i 0 73(�`J
4 I certify that the remains of the decedent identified a ove were disposed of in accordance with this per ' .
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ILI Date of Disposition 3/l I(( Place of Disposition pli#14 ►e�J (.. o,,f0rw-..
2 (address)
iti
CC (section) jj (lot number) (grave number)
Name of Sexton or Person in Charge of remises tir,$ M e .,,,.e
(please print)
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irk Signature Title C2 r i1 it i O ..
(over)
DOH-1555 (02/2004)