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Wendell, Gerald NEW YORK STATE DEPARTMENT OF HEALTH ft gZ Vital Records Section II Burial - Transit Permit Name First LI era\C� Middle" a Last `-I -en a e\\ Sex tn Date of Death 1� 1 2 I 1 Zv)s Age�9� If Veteran of U.S. Armed Forces. �} ( ^ I -1 ' War or Dates CD C\ j ; Place of Death i Hospital, Institution or Ci1y)Town or Village G lens F"a\\S Street Address G\en3 FcC\\ g) 1 1p Manner of Death®Natural Cause 0 Accident 0 Homicide 0 Suicide riUndetermined Pending Circumstances Investigation Medical Certifier Name Title �(\ SUZC1n \i M' R c eS , . 1 Address iqi \DO }?ar1L S--1 ee. - Glens Falb S t '/ 1 zgb) >> Death Certificate Filed irTh N 1 Distric Numbe5 \ Regist mb�r it Town or Village c- �r Date • Cemel ery pi Crematory >:: ❑Burial \\ ' Z— \ Z-o� 5 \--In e. V ;ev) C ce�c�na\-O'y Address �V Z \ Q�eenbv�ry _I NNI. \70 1 ®Cremation pG�CI I Date Place Removed . g❑Removal j and/or Held •• and/or Address ' Hold O Date ' Point of os Q Transportation. 1 Shipment a by Common Destination Carrier Disinterment Date I Cemetery Address Reinterment Date ' Cemetery Address Permit Issued to Registration Number ' Name of Funeral Home Pte-,� ff.;A, 11-& . l N� ©i13�_ ` l Address 4,-7-7-1,--- -7-' , 0 va.:-/JS a orti 1 1 2,r-d LI - Name of Funeral Fie Making Disposition or to Whom I Remains are Shipped, If Other than Above Address 441 Permission is hereby granted to dispose of the human remainsZribe ab ve icated. MI /6 Date Issued 2 V 20/� Registrar of Vital Statistics . (signature)e) /� District Number S-60% Place C/ ,/ 6!5, N/ I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: F W Date of Disposition Walls' Place V rr'' Place of Disposition ,../ Cer., a-- 2 (address) W CC (section) Alt, um (lot ntter) (grave number) GName of Sexton or Person-in Ch ge of Premises JtKnt(4 (please print) a: Signatured • Title (P M- - (over) DOH-1555 (9/98)