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Guilder, Earl if NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Tran it Permit Name First /Middle /�Ltaas� Sex �r 6 C9 '< Date of Death Age If Veteran of U.S. Armed Forces, ,,),h( fa,/ r; gL War or Dates lw Place of Death Hospital, Institution or Z ,�} Town or Village (Lets �;Its Street Address Limns III 3� ' . ner of Death©Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending W. Circumstances Investigation tit Medical Certifier Name Title 0 'L/ - '.-P --('cL 7--z e_i I; /1b- Address 4Z,---,t-, 1-1-7 1 o'D ��ri/ s4, �Letis- pti I�I 1 a.�S Of Filed District Number Register Number {p�Certificate Ci own or Village �Le`y ``IIs� J 6° ❑Burial Date Cemetery or Crematory I// ao ( 7 , ,,cv,,, CeMc-f-� DEntombment Address ©Cremation A .Sbur /)L�...,`Jar( Date Place Removed Removal and/or Held and/or � ; Address fib Hold 5 Date Point of 0 Transportation Shipment O by Common Destination E:l. Carrier ❑Disinterment Date Cemetery Address ❑Reinterment Date Cemetery Address Permit Issued to "_ _ Registration Number ilir Name of Funeral Horne' cA,.�vfe- 1 L,t,1er. [ /4--, _mot 0 o `1`1X < Address I<' Name of Funeral Firm Making Disposition or to Whoa( 14 Remains are Shipped, If Other than Above Address w Permission is hereby granted to dispose of the human remains descri e abov as i ed. 'z Date Issued l 3 /A 0/7 Registrar of Vital Statistics _ (signature) !iiiiiiilr [i I District Number cCac� ( Place ��en5--� 11�r✓ /�Je-� /or< s I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: ui Date of Disposition 1 / J I(b _ Place of Disposition 4L� G t c. "vrt - (address) la CC (section) (lot number) (grave number) QName of Sexton or Person in Charge of remises (LT, S=�nt� z (ple se print) Signature el Title GE€mfl (over) DOH-1555 (02/2004)