Simcox, Andrew A. 0 # M
NEW YORK STATE DEPARTMENT OF HEALTH Burial
Records Section _ Transit Permit
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[C[.� Name First remt � i MCA* ` '�"'
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Date of Death ii Age ( If Veteran of U.S. Armed Forces, w .
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stutir Street Address
own or Village Undetermined �Pending
Manner of DeathNatural Cause Accident Homicide Suicide ❑Circumstances Investigation
Title
Medical Certifierifj Name Me i I SSA D-e 6 e e r- MD
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< Address q C0 / `) a\ACLQ-n f C�► kN i 2-qoO
=;: Re ister Number
-. h Certificate Filed / District Number
n'IMP own or Village G ui-'n S a-�` i 5-Q 01 - '-1 5�
Date ��t 5 I Cemetery�remato3) Q RR_0 Burial
Address_::Cremation QU�C�-� fa—a Q t_A.�S�.S 1 t,'L_z i ,i 1 2'i3C-)y _
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Date Place Removed
0❑Removal and/or Held
and/or Address — — -- — _--
u- Holdth
0 Date : Point of
Nn Transportation _ } Shipment
a by Common Destination
Carrier
Date Cemetery Address
C Disinterment
Date v Cemetery Address
❑Reinterment I 1
Permit Issued to / 1 Registration Number
.i Name of Funeral Home Halm ci b &Q-ker ��n�rct/ jomC, 1 of l 3c
i Address /i LCCEO- c-tft (Y. , bLi cens&c-r`I , /Um) L%v-k- J J oL/
Name of Funeral Firm Making Disposition or to Whom
ii,Remains are Shipped, If Other than Above
rAddress
10
A.
Permission is hereby granted to dispose of the human r ains d cribed ab ye as indi ,te .
qg Date Issued Registrar of Vital Statisti y,
(sign re)
`<: District Number,�`�lr>D Place }�A/
,. I certifythat the remains the decedent identified above wer disposed of in accordance with is permit on:
f-:ii:
:
LiDate of Disposition 7/Z II J6 Place of Disposition "I a—✓ re—..---
a (address)
U)>C (section) dot number) (grave number)
Ct Name of Sexton or Person in Char e of Premises C �r,.i-L. �
A 4' (please print)
44 Signature
Z frbeNfitit
(over)
DOH-1555 (9/98)