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Venables, Michael i is 91L1 NEW YORK STA.TE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First AA v Middle Last Sex 1 / Date of Death l / Age If Veteran of U.S. Armed Forces, I?-/a`f -/04L'i i� 7 War or Dates ZP of Death Hospital, Institution or r/ ' W i own or Village (1�s, i(l r-- Street Address ‘LeAs _... i 0 anner of Death(7 Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined Pending III U 4�� Circumstances Investigation ill Medical Certifier Nam 4..44.. Title > Teo�anA ✓,l Address too Aarr4' 51 .6L.e.ts- a--„, �r /.ga i a- Certificate Filed District Number Register umber - own or Village ( te.-r�� 5 0 ( (0/g . ■Burial Date Cemetery or Cre tory ::x, ❑Entombment la /� dv/ � �A e V;e, , (./e"', �•i/ Address _ V [3`Cremation ��Vt,e-ens��/�' ) A} /r✓t, I,2{3oq • Date U Place Removed Z❑Removal and/or Held 2 and/or Address • gHold 0 Date Point of i ❑Transportation Shipment . 0 by Common Destination Carrier ❑Disinterment Date • Cemetery Address . Reinterment Date Cemetery Address iZ Permit Issued to ----- Registration Number 1 Name of Funeral Home s'u.,,rc I ...ti1 c ( 1-10 i ©c, Y'-ti Address 3er.., / • 7 A v_e_/ (� /( �• ` iG2 to_�-' ,' Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above 2 Address to • Permission is hereby granted to- dispose of the human remains described above as indicated. 'Date Issued I a,/aw/,A o I C Registrar of Vital Statistics O --QUk.).-A-"-CeACr (signature) District Number 5 GO j Place 6 s -\\� I y 1-- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: 2 ltCtf Date of Disposition I Z�-'15 Place of Disposition p/he �1, J G,e,„z ,� ilk (addre§s) 11.1 to 'lam (section) / (lot number) (grave number) tiName of Sexton Person in Charge of Premises )1,114A 64 rnac 42 z (please print) 144 Signature Title C-ce-r.-7w01-ar (over) DOH-1555 (02/2004) •