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Lydon, Leslie rDEPARTMENT OF HEALTH yi ., section Burial - Transit Permit Name First / Middle Last Sex LE3 C L 1( 1.4f ��7)Ln) 3/7,f�Z,t3. >= Date of Death Age If Veteran of U.S.Armed Forces (�j29 if 2 1 I War or Dates -J/i 144 Plac ath Hos ital Institution or l City Tow r Village Q u C-Z-A.)s d t eet Addres 3 ay ,1�/c; Rp o ry &VI Manner of Death f Natural Cause El A ent Homicide El Suicide Q Undetermined Q Pending lsf Circumstances Investigation l t Medical Certifier Name Title �r 0 16- ..0,' r✓►ev . fq/2 i:/ Address /o.' pGg L/1c �j, , �j��s A// ✓Vill / g-©/ Dear• _-:,, -te Filed i DistrictlNumber - Regi �r Number C , Tow • Village ��( ',J (j(D/L-- • �)iim C El Burial Date Cm ❑Entombment 62/2-9 Z Ce Ii Y�c:tery • Cr- ato, !Cam.-.) Address ziz` remation (Jz )C � CR) lS ,.� a I2 o . ] Date dace Removed a L� il Q Removal and/or Held J ....k and/or Address Hold Date Point of 65 Q Transportation Shipment by Common Destination Carrier _ Q Disinterment Date Cemetery Address Q Reinterment Date Cemetery Address Iii Permit Issued to Registration Number Sii Name of Funeral Home VA(*plat ', 6a_ker Funerai k1tb r O i 1 3 0 Address 11 L-aF0,yC.1-}e- S4. , Q uewsbu,ry , N e vs-1 ycirr IL 12 S?o y '`'<° Name of Funeral Firm Making Disposition or to Whom 1Remains are Shipped, If Other than Above Address Permission is hereby granted to dispose of the human re ins described abo as indicated. XIii Date Issued !p _ ;-y, 4-e,r,_ Registrar of Vital Statistics (signatur IP District Number g s-__.) Place Cf2 _,_,Q. 9 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: k a Co.-,,to to Date of Disposition -)12(a Place of Disposition ��Utcrw _ (address) to t1! I (section) a (lot number) (grave number) 0. Name of Sexton or Pers in Charge of Premises t'�t`��� �l�� '" (please print) Signature Title Cit+rtM(khOrt- (over) DOH-1555 (02/2004)