Griffin, Ralph NEW YORK STATE DEPARTMENT/OF HEALTH ..->
Vital Records Section Burial - Transit Permit
Nam !(irsth Mid¢ie
vrl rr, Last Sex
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Date of Death Age If Veteran of U.S. Armed Forces,
c))- ao 1 4 g'g War or Dates ►9j- (q-q el-to
I- Place of Death Hospital, Institution or
W City,Gown a Village,j G in n S(q Lk.,t--ci Street Address Act, no ri�aG t. -Fri ( AM
Manner of Death®Natural Cause Accident Homicide Suicide Undetermined ri nding
ILA Circumstances Investigation
ili Medical Certifier Name Title
4 Ja s , rr ) ndSan M /�
Address
Death -rtificate Fileq District Number .. Re ist Number
City,tilt or Village DI. nSka_(-- �j� ,
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❑Burial Date C.ietery or remator�
El Entombment S I \ IL, ' ne 1 e ) -c.,, ,... `" Yc j
Address
Cremation Q ,h S�u r N\/4 ,i4 '
Date Place emoved
Z ❑Removal and/or Held
and/or
ET
ti Hold
o Date Point of
ti❑Transportation Shipment
0 by Common Destination
Carrier
0 ElDisinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to � n Registration Number
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Name of Funeral Home I , I }e- �yyj( yykA_, 0 11 c q
Address
P D Pj nc -7 i i nk L a , La,Kst. NA/ 12$4-4-.
;;. Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
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` Permission is hereby granted to dispose of the huma remains described a ove as' dicated.
Date Issued 1(o Registrar of Vital Statistics a I
(signature)
District Numbers(, Place J 0 tD n cA pk n s bt t f-"
:;; I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
1
ILI Date of Disposition /eZ-//4, Place of Disposition P 11 Q ()rCid G/urt r�r
(address)
W
Ul
Cr (section) (lot number) (grave number)
its Name of Sexton Perso in Charge of Premises J 6-i t_v1 ae-Le
(please print)
Signature Title -re-- �o
(over)
DOH-1555 (02/2004)