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Blanchette, Joan NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit g Name First �_ Middle Last Sex r - Jaa�n hYNn BCtnche- 1- - ' Date of Death I Age I If Veteran of U.S. Armed Forces. ,,II�� d3)Dt} i aDi u 1 $i j War or Dates Ni IT _ 1. !!P e of Death I Hospital. Institution or >a (S Town or Village Street Address �`"�, ` 11a�, Ii Manner of Death g ���'nSl\� GI i'r.l�`S � p1 T��l 7 Natural Cause El Accident 0 Homicide 0 Suicide EI Undetermined ri Pending Circumstances Investigation iai Medical Certifier Name Title Address It:0 10© %)00 0-- S - e - - -e n S VokAS, 1 1-z-M I ''s' Death Certificate Filed I District Number - I Register Number Ci y, Town or Village �`ens c—cx,1\S f 5 6 o 1 !- 1 t 6 Date I Cemetery or Crematory ❑Burial j `-�3=7 1()(a* I aZD\V2 j P i P V► e u..) C rerna-\-0{. Address : l.Cremation1 QUeens1:1vJ i N r -Bo , Date / ; Placey Removed 0 ❑Removal I and/or Held and/or i Address a Hold 0 E 0 I Date Point of 1 n Transportation ,1 Shipment 5 by Common Destination - - • Carrier Disinterment Date I Cemetery Address Reinterment I Date Cemetery Address I • ipii Permit Issued to I Registration Number -_ Name of Funeral Home - -_ - I '--- _ j / Address i ., � t;f - %% - P�'"ITT I Z�- %. ;)i-)cZ/-15;. C. 1tc i i 1.' . 1 2.-0 C? `/ '<' Name of Funeral Firm Making Disposition or to Whom "` ' • h Remains are Shipped. If Other than Above `� Address Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 3 17//6 Registrar of Vital Statistics (A) . W-A-A-c.63.4 '` (signature) District Number 560 1 Place 6 5 Fa \5 , W y I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: XDate of Disposition 3/1 1 iL Place of Disposition Zfte L Crr oriu,., 2 (address) LU U) CC (section) A (lot number (grave number) - QName of Sexton or Person-in Charge of Premises L hr,� imM� z (please print) 44 Signature U !' Title OEMOIL - (over) DOH-1555 (9/98)