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NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name FirA) ( Middle Last t C, tiff') Se
Date of De h bt,�I Age If Veteran of U.S. Armed Forces,
` 1 War or Dates
Place of D ath , Hospital, Institut*n or
11 City, Town or Village 3c,,,„\,.,,ut,f3 Street Address A r/t" ;.)i'/T4Z-
tzt Manner of Death O Natural Cause O Accident O Homicide O Suicide El Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
0
Address
Death Certificate File District Number Regist umber
City, Town or Villagep� \roCif-) 1
Burial Date metery o Crematory
1-2,i--i, V.2 \j\t,-J kit/-}—to
DEntombment Address
OCremation �.)G� A7
A-4 .
Date t Place Removed
O Removal and/or Held
.a and/or Address
h-a Hold
0 Date Point of
j Transportation Shipment
ct by Common Destination
Carrier
El Disinterment Date Cemetery Address
O Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home
Address
``> Name of Funeral Firm Making Disposition or Whom eiRemains are Shipped, If Other than Above � � �/��� �t�A2_ 1
Address
ff, Li 07, ‘i.._ ,-. .X'\) . . Ditqst- xpt- - VAivi`,45 jU(-1 )2?t,a
4:1` Permission is h reby ranted to dispose of the human remains described above as indicated.
Date Issued Registrar of Vital Statistics
(signature)
District Number ( `ss-01 Place �� -`,`-�' ()Et�k�
1. I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI Date of Disposition 3-ZS1b Place of Disposition gi ¢,-+ nw
W (address)
(1)
CC (section) Ai . (lot number) (grave number)
aName of Sexton or Person in Charge of Premises Atst « St.,r&i
z (please print)
W Signature Title CeE4I4111I1
(over)
DOH-1555 (02/2004)