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Gebo Sr, George f 70 NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Napes Firs Middle Lam Sex k, Date of Deatt1 A e If Veteran of U.S. Armed Forces, 3- D1(3-3 Z v ' War or Dates Mo t-- Place of Death Hospital, Institution or [ f City()owrtpr Village ` Street Address (o3 A(_ Rd p Manner of Death cg Natural Catise ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending LU Circumstances Investigation W Medical Certifier Name Title C) EdGoct-rd Leers il4D Address 5 --focia Se rdc2 I ns '`[strict Death Certificate Filed D strict Number Re aster Number City To or Village -1 ❑Burial Date Cetery oremato eu) C -yosa..y-en7 ['EntombmentAddren. ` ` ne, " " :!,Cremation L -0-44 5 b unit Date J Place Removed Z Removal and/or Held 21-1 and/or Address Hold to 0 Date Point of E Transportation _ Shipment 3 by Common Destination Carrier El Disinterment Date I Cemetery Address El Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home \skjrt 'k.ke..ra,/ '/j� f yle__ &Qo'-if Address PO 3o') 9X) Late _ L ie r-,q 1Z61/6 Name of Funeral Firm Making Disposition or to Whom I Remains are Shipped, If Other than Above • Address lit UI 0`. Permission is hereby granted to dispose of the human re ins described above as indicated. Date Issued 3 _ ///I Registrar of Vital Statistics signature) District Number l71��� Place I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: ili / © • Date of Disposition 3/9 hi.hi. Place of Disposition Kuhii') it„d wm aN^ 2 (address) la 41) CC (section) /1 (lot numb r) (grave number) za Name of Sexton or Person in Charge of Premises A�r,�-'` " er,.jir Z Y(please print) W. Signature k�' Title MEWL L (over) DOH-1555 (02/2004)