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NEW YORK STATE DEPARTMENT OF HEALTH Burial Records Section Burial - Transit Permit
Narpe.. Fi st idle Last S x
:A 4__ Sch ill -Pr,n i l Femak,
Date of Death Age If Veteran of U.S. Armed Forces,
_ Z� `2O1 5 $cl War or Dates If 0
H Place Bath Hospital, Institution or 1 I
W City, w_r,o r VillageI L i L., .14- -r'}, Street Address I r),—] i'-h 610IM - Valk
k t- Rd
p Manner of Death Natural Cause 0 Accident Homicide 0 Suicide Undetermined 0 bending
111 Circumstances Investigation
W Medical Certifier Name Title
o to i! 1n Ops-te,11D NI b
Address ,
17' LUash I nJ 1 o n Sct . AJ ba.n y 1'l a1 y i 3
• Death rtificate File District Number /Registe umber
City, Tow or Village�,KQ l�p�� `��
.❑Burial Date netery o Cremat ry
Y ❑Entombment O -2, 201, c .
Address
i l 1,4 aCremation QUe;(',m ,.�,
Date Place emoved
Z C Removal and/or Held
and/or Address
H Hold
V)
Date Point of
NQ Transportation Shipment
a by Common Destination
a Carrier
Date Cemetery Address
i3:
Q Disinterment
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
ti Name of Funeral Home-B i'-P i.0-c,r- 1 v e,tom( 4- r sL I►`K (( -(
. Address
q- 0,hurch St La.kr zer-ry N� I Z g 4-hp
i •
Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
2 Address
W
n,,,Permission is hereby granted to dispose of the huma re ains des ribed abo e a indicated.
Date Issued 2.-Z3 ' 15 Registrar of Vital Statistic jii,/ MA
s '^ (signature)
District Number f Place f L-� L r— _
ye �J(G`J lv O(,c3►1
H- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
UJ Date of Disposition 7/74i5 Place of Disposition Rta Cr.r,Klr.,,,,,
MI _-- (address)
co
c4 (section) (lot numb") (grave number)
O Name of Sexton or Person in Charge of Premises kfri.._ ;Je
z 0 4._ (please print)
W Signature !sue Title o"�'
(over)
DOH-1555 (02/2004)