Eddy, Deborah _ A if q i
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transii Permit
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Name Firstly f"" k Mjddle �0 ast4 Sex
Date of Death • i Age If Veteran of U.S. Ar d Forces,
/ V/ a Pit' I War or Dates
1- Pof Death Hospital, Institution or
� own or VillageA-1..6„..,1,.....---
t:t> Street Address M-L5.c,� Mt.r of Death Natural CauAccident Homicide Suicide determined Pending
Circumstances Investigation
ul Medical Certifier Name Title ,o/
L1 U�,13.(r 4 �1 �f �v�/ o
Address dJ
joaeatb,Certificate Filed District Number Register Number
;;.I...�Eity. wn or Village ,,/.�Lb,.,.. 1 U i
Bi: DBurial Date / /r/ Cemetery i Crematory I
❑Entombment , 6 i� �(�/�B r n�`�`a.w �^ -'�
Address resss
[Cremation cAz_e15,;„r i‘i
Date 0 ) Place Removed
Z Removal and/or Held
2 ❑and/or Address F
Hold
0 Date Point of
ti ❑Transportation Shipment
0 by Common Destination
Carrier
El Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to • Registration Number
Name of Funeral Ho ,,.,,,-e. rane_... L . !3'-1.____ e.,,?`-
Address 7 dt,SAtx• AV S'''1%t4-1:::4•-•-.-- -/Li 7 / 2_,S. 2--
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
tr.
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Permission is hereby granted to dispose of the human remains describ indicated.
Date Issued 6/7/a0/6Registrar of Vital Statistics 7r'h
(signa�7te} .— ,
District Number Place / 4 j, ,� , /;(-ior--
ILL
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
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l� Date of Disposition (o Ito t/b Place of Disposition ge.,04,„../ 4rftpid,4„-
(address)
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IA
IX (section) A (lot number (grave number)
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Name of Sexton or Person in Char a of Premises ; 3 Ln --
z ( ease print)
Signature Title CafX
(over)
DOH-1555 (02/2004)