Cole, David NEW YORK STATE DEPARTMENT OF HEALTH
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Vital Records Section , ; Burial - Transit Permit
iAi Nanke First Middle Last Sex
l_ CIq i(1 f\.-\ & re, lVictie
Date of Death Age If Veteran of U.S. Armed Forces,
- ID 4 i' I War or Dates I ci73- K 7(fi
I .— Place of Death Hospital, Institution or
City, Town or Village Street Address
Manner of Death®Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
W. Circumstances Investigation
iii Medical Certifier Narvq,, Title
nor Mui4tc&, MI)
Ad ress
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Death Certificate File District Number Register Number
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(Cit Town or Village�,,(--G' T \')f)r 11155
❑Burial Date ,Cemetery r Crem tory
❑Entombment UV g 3 "20t✓L#f Ti tie' V(.,u� 1WdOra
Address
;:,®Cremation (t .A bl .v-1j
Date I Place Removed
Z Removal _ and/or Held
2❑and/or Address
Lt Hold
r
0 Date Point of
r) Transportation Shipment
G by Common Destination
• Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to t_ Registration Number
Name of Funeral Home (�' k;.ea -f l,Llley 11--O c , 1 h L. 0 0).11
Address
.4 Cflr i Fin St La ,6_ L1,17,t-r-t, Ny I L 74,
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
at.
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Permission is hereby granted to dispose of the human rem ' scr' ed ab ve as indicated.
Date Issued It --13 -2010 Registrar of Vital Statistics Te -4-tit44Ncik
(signature)
District Number 40 1 Place (\+ . ���_L� � �I i
l~
I certify that the remains of the decedent identified above were disposed of in accor ance with this permit on:
6 Date of Disposition to(i5//, Place of Disposition gfti t,,/ Z-iinC4,40/1-
2 (address)
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CC (section) /� (lot number) (grave number)
Name of Sexton or Person in Charge of Premises /125 trl$
(t please print)
1 Signature L Title alL444173V-
(over)
DOH-1555 (02/2004)