Derby, John 7
NEW YORK STATE DEPARTMENT OF HEALTH b Z
Vital Records Section Burial - fransit Permit
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Name First J O1.piMTddle I�/ t r Sex J
Date of Death Z_ Age Q 5 1 If Veteran of U.S. Arme Force ,
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- Place of Death Hospital, Institution or J ,
ti City, Town or Village Scc-c�'a f e, G— S p Street Address J' ZI& e I I '"e S 1,
iu Manner of Death Undetermined Pending
Natural Cause Accident �Homicide �Suicide � �
IiIJ Circumstances Investigation
W Medical Certifier Na a Title
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Address 3 4) ��O 4-14-/( 41-?
?Death Certificate Filed z � �^ L District Number /i50Register Numbe
City, Town or Village 0 P J/7 �l i
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Date Cemete Crematory/ �/Burial �� io
ry✓ re 1 V I eGc1_ Grey' c r
Entombment Address Cremation 2_ ( Q (,�a.�( R (.�/�. (o_S o u /09
Date Place Removed
Z❑Removal and/or Held
and/or Address
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0 Date Point of
ft❑Transportation Shipment
L3 by Common Destination
bi Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to / Registration Number
Name of Funeral Home (��✓k c c i ��,Le_v At c. .' -€ 00 3 C-7
Address
40 2 lam-&-p C-e_ 1---tee ,/et 50- 5p tiY l Z 86C
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Name of Funeral Firm Making Dispos ion or to Whom
Remains are Shipped, If Other than Above
2 Address
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117 Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued q_ 6 - (C Registrar of Vital Statistics tP%,,,N -P. -4-(11.4,..1
(signature)
District Number (-156 ( Place 5ct,ir4.-E>56,_ 5/0.
I certify that the remains of the decedent identified above were disposed of in acc dance with this permit on:
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W Date of Disposition 91b16� Place of Disposition to)Pk/ �rn,nor u.....
2 (address) ll
ill
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CC (section) (lot number) ' (grave number)
DName of Sexton or Person in Charge of Premises ' l' . 4.44y
z ( lease print)
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Signature -� Title IM,I r 1`
(over)
DOH-1555 (02/2004)