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Wanderer, Phyllis NEW YORK STATE DEPARTMENT OF HEALTH ) ' N it no, Vital Records Section Burial - Transit Permit Name First IN MiddleLast Sex rkti �.LkS �N a- Sti P Date of Death If Veteran of U.S. Armed Forces, H. 3 �► `s Ag War or Dates 1-,A I-► Place of Death Hospital, Institution or City, Town or Village a1-6 AN Street Address A1.4b A NJ Lk M C O ►LA`. C 'T'i L'2, ttil Manner of Death j Natural Cause ❑Accident ❑Homicide ❑Suicide El❑Undetermined ❑Pending IliCircumstances Investigation In Medical Certifier Name Title L, 2.6 A1-1 G rt.7 Address 1\01L1-4 l`3 N -'- mod;iA -' AV AL N 1`J 1a2(1' ,; Death Certificate Filed District Number Register Number City, Town or Village j O ) O 53 R ': < OBurial Date 03 I cs / �o1s C etery or Crematory 14. %, .., t.;rAA-r o2ti ❑Entombment Address..., ;; 6Gremation v v r.£Ns'S v---4-c N\ )1(04 AK.+;R e.oc.') Date Place Removed ❑Removal and/or Held and/or Address ri.7 Hold Date Point of giEl Transportation Shipment a by Common Destination pil Carrier ❑Disinterment Date Cemetery Address ❑Reinterment Date Cemetery Address glii Permit Issued to � " Registration Number Name of Funeral Home M ALI Ni1� 0- L�qk 0. Ft.,.,.,E.Q,a� 14a „: 0 11`3d i Address ( \ LA cw., T1 E ST QLj t ci-,s ko Qti >J'A tUO`k iiiii Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above • Address cr Ili Permission is hereby granted to dispose of the . emains described above a, indicated. i; Date Issued u�/u ; !S Registrar of Vital *.statistics ; Q 1 ignature) District Number j©/ Place ,. AU, „,„„,„, ,„„.::::„:„,:, I certifythat the remains of the decedent identitT�d a ove were disposed df'in accordance with this permit on: P I ( l� „�IL• Date of Disposition 3�1<<l� Place of Disposition 1f is (address) In w lM (section) {! lot number) (grave number) ja `Name of Sexton or Perso in Charge of Premises 34(j6s - _Sty"- (pie e print) • Signature Title (iV r►calLL (over) DOH-1555 (02/2004)