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Marcotte, Carmen NEW YORK STATE DEPARTMENT OF HEALii ri,. I `Z Vital Records Section Burial - Transit Permit Name First Middle �Ai. Last Sex s. Date of Death Age / If Veteran of U.S. Armed Forces, 3'/11 [a ca f( C'2 3 War or Dates }_, Place • •eath Hospital. Institution or �n Z O H, Town or Village C4,r.v� Street Address 377 Av !n�p , L-6- 63 .4Ma Death Natural Cause Accident E Homicide Suicide U etermined — Pending Circumstances —Investigation W Medical Certifier N Title CI ���. � Mei S 1/'i ct AA i i't'l -r) • • i Address Ca,? Levu,/ r,cky• ,i, y� 0 a 8 6�; Death cate Filed DistricteMur bdr Register Number City 6o r Village �0 r:A-61.-- e"5 53 Date Cemetery or Crematory Burial 3/ I i / , v t( C , Address 50 Cremation % ./ �j „.een5j,,r Date `✓ Place Removed O -"Removal and/or Held H and/or Address O Hold O Date Point of Transportation Shipment Ei by Common Destination Carrier ^'Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home ,tj;L�'ISM,rc 7`�.,c c t, 14—ei _ ©0 2 i Address 7 ,51ec...-� 4ve r,. AJ. I i `1 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above 2 Address u Permission is hereby granted to dispose of the human r-- :scribed ov s ' icated. e Date Issued 3 6 Ct /aar( Registrar of Vital Statistics fib .-a ire) Place �1 �-f- r,�:..-tv�""_. District Number LI'S5� I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: wDate of Disposition 3--I1- t( Place of Disposition Po.idtov C0.14 fd rr0Y+. (address) LU CC (section) 4 _ (lot umber) ( rave number) • Name of Sexton or P son in Char of Premises rt,s 3tthNF z14 (please print) LU Title ME. l4Td Signature � n'1 O- DOH-1555 (10/89) p. 1 of 2 VS-61