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Leseauet, Rejean NEW YORK STATE DEPARTMENT OF HEALTH . \ t. 1 , Vital Records Section Burial - Transit Permit Name First Middle Last Sex Date of Death Age If Veteran of U.S. Armed Forces, qtal )I ' Lcii War or Dates ---. 14 Place of Death --- Hospital, Institution or g City, Town or illage ,,,c,_ (9 le'vs -F-,U)y✓ Street Address /o L hot,;, S & Manner of Dea Natural Cause �Accident ❑Homicide �Suicide Undetermined 7 Pending Circumstances Investigation Au Medical Certifier Name Title Address i,5 )-- Pier 17\ / S& c Le s" 1`c4L N i ' J5 c3( Death Certific. ; . -d " District Number Register Number ill City, Town .r'Village 6 , r'e45 --,iIV- 4S ),.`- S - Cemetery or Crematory ❑Burial 7A5—/dol)— ,1e-v;cLI 6eNksr t Address - ©Cremation d I, ✓ 4 Date Place Removed 0 Removal and/or Held t, and/or Address tti Hold 0 Date Point of FA Q Transportation Shipment a by Common Destination Carrier El Disinterment Date Cemetery Address — Reinterment Date Cemetery Address —iiiiii' Permit Issued to ,�% s Registration Number Name of Funeral Home c.-nSr"orc_ �, 4.) ,i„,. 6 b fi1? Address • Name of Funeral Firm Making Disposition or to Whom ' dia.ilfrt" Remains are Shipped, If Other than Above Address CC 141 >; Permission is hereby granted to dispose of the human re ins describ above as indicated. Date Issued -A f Z`1, �- Registrar of Vital Statistics 2c UC.. (signnature) iiiiiiii;i District Number t}5Z4 Place L9L.G�n,_ ((c-/ 0, / niiiI certify that the remains of the decedent identified above were disposed of in accordance with this permit on: I- 6 Date of Disposition 1(71-(It- Place of Disposition '8'4UoCJ (L -- t (address) w N CC,.., (section) a , ( t number) (grave number) Name of Sexton or Pe son in Charge Premises ill Strive" Z (please print) • Signature 4p1, Title C ei r 04, DOH-1555 (10/89) p. 1 of 2 VS-61