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Chant Sr, James NEW YORK STATE DEPARTMENT OF HEALTH ' Vital Records Sectiaii Burial - Transit Permit j Name First fi Middle A Last Sex LarryC\ncon�- Sr, �\ Date of Death Age If Veteran of U.S.Armed Forces, of 5 2O\Lo 3S War or Dates N1'(� '`< Place of Death Hospital, Institution or Ci own or Village k �a\\\C IStreet Address G lens Fri\\S 4)oSpi�- .1 Manner of Death14i Natural Cause Q Accident 0 Homicide Q Suicide Undetermined Pending Circumstances Investigation ' Medical Certifier Name Title Arl P ey-►c P 31c ayl iti Address J J :&:' toc io.r'- S-'�..k-�- GLens �el\\s ►v 1 iz�o i Death Certificate Filed District Number r Register Number it sty, own or Village G i ey s Fa)ti Date Cemetery or Crem`It ry ❑Burial 01 104.9 ) Z©i[D .P'oe_ V;et.° neverna fort Address ::: ►.1 Cremation Ci t/LA\C QY 121 d, «eensbo r 1 /Q)I 12 D y Date Place Removed Ow.D Removal and/or Held tiTi Hold and/or Address _.__.._ Date 7-Point of Q Transportation i j Shipment by Common Destination, Carrier : ,Disinterment Date [ C.;emetery Address .• Date 1 Cemetery Address -• Q Reinterment A Permit Issued to Registration Number k>3 Name of Funeral Home emay\eys N Qi\ )-1 p'(n f 01130 0 Address lit 11 Lo,.-Caye4e S\-eee-\- i ( , v' \roYy i M\I i Zg09 f. Name of Funeral Firm Making Disposition or to Whom • Remains are Shipped, If Other than Above • Address Permission is hereby granted to dispose of the human re sins de bed ab a as indicated i {F Date Issued n 1 ii01 f , (sig u ) '` District Number. 7jQ 1 1T1Place I certify that the remains of the decedent identified above were i posed of in accordance with this rmit on: 1 iDate of Disposition /^7-kJ Place of Disposition f in1 e v,24.,J C ce-ena-6,r y (address) IA (section) (lot number) (grave number) • Name of Sexton or Person in Charge of Premises_ ;.t ),G � .ben) - (please print) U Signature (i Title e ,r iv.� (over) DOH-1555 (9/98)