Starzec, Carrie NEW YORK STATE DEPARTMENT OF HEALTH (it
Vital Records Section Burial - Transit Permit
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Date of Death Ag If Veteran of U.S�. Armed Forces,
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i-. Place of Death Hospital, Institutio or 1
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Circumstances Investigation
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A Death Certificate Filed ` Di rict Number Register Nu ber
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❑Burial Date _ emete r Cremat
) Entombment
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Cremation -e_.0 0( b\k(, t\,
Date J Pllae Removed
0 ❑Removal and/or Held
and/or Address
Hold
O Date Point of
N0 Transportation Shipment
n by Common Destination
l Carrier
s ' Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to -� Registration Number
Name of Funeral Home , ) '(,� ( �� �� Dri ( ) n L Q OZ 1 I
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` Name of Furieral Firm Making Disposition or to Whom
I- Remains are Shipped, If Other than Above
2 Address •
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JZ Permission is h reby ranted to dispose of the human rem ' cr' ed aie'� indicate .
Date Issued '�?� i''� Registrar of Vital Statistics t
(signature)
IDistrict Number 9`3'to' Place SARATOGA SPRINGS
NI certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
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W Date of Disposition 74 Z(.IIr' Place of Disposition I;M1� "-
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(section) j14 t number) (grave number)
O Name of Sexton or Person in Charge of Premises �,/4/� �°^
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Signaturela
-- Title CO'"1► .
(over)
DOH-1555 (02/2004)