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Eaglestone, Patricia NEW YORK STATE DEPARTMENT OF HEALTH .. ' g Vital Section Burial - t r \ ransit Permit Name First Middle Last Sexs ockr;co, E\te'c Ea-SieSi-bne JEl(ri. ' Date of Death If Veteran of U.S.Armed Forces, .ram. Oc\ 114 1101 40 13 War or Dates /J I Pt = Place of Death kiospita r�stitutio City,(fow far Village 0\)e-en80Ury Street Address Q r e`!‘ O2.f1 (- ...YD Natural Cause p Accident El Homicide ❑suicide El undetermined Pending Circumstances Investigation Medical Certifier Name Title r �OS LI ^) Eoco t- F- /('/A 12 Address 1 �f uvc.v b z,"(.,-- cotfe.„Jss 6 / Death Filed Number-� uv, - ter ber"J 6 city,4 �l.,it rValage ��e`flslovey CIM 5��� �0 /07 Date �q \ ,� ' Cemetery or Crematory El Burial ail l a p \Le. 0 re vna_VC)r Cremation ©V 0.LuY Q.Cx0.Ct - of e nsb ur 1 Az-RN Date Place Re olved 0 Removal and/or Held r,: for Address vi Hold 0 Date point of 0Transportation (Shipment a by Common Destination Carrier _ ::::Q Disinterment Date Cemetery Address Q Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home a er FUJ)t fCLI Homes F Address l( �/13� Lafa.t-0.1te af. , &GLILeinbUnd I Aim) yank. l aSay Name of Funeral Firm Making Disposition or to Whom - Remains are Shipped, tf Other than Above • Address ' Permission is hereby granted to dispose of the human ins d 'bed as indicated. >N Date Issued 1 t c I 1 l Registrar of Vital Statistics C-_ C d1m �' (s e) District Number C Plane 16 0.----„ �� S' I certify that the remains of the decedent identified above were disposed of in with this permit on: M Date of Disposition 112 1U Place of Disposition en,VI{,w 6,ma rcr a (address) fLI DI (section) (lot number) (grave number) fl Name of Sexton or Person in Charge of Premisesl I f 0 3 t+1 ri- g l (please print) I /' w Signature (�-C Title Clif M A Pit • (over) DOH-1555 (9/98)