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Merchant, Marie NEW YORK STATE DEPARTMENT OF HEALTH > ` s7 Vital Records Section Burial - Transit Permit Nail\ a First Middle Last Sex aria Nile rcha y+ Pie_ ate of Death Ate If Veteran of U.S. Armed Forces, ( - 1(.0- 10(5 jr War or Dates sij Place of Death Hospital, Institu or (.dry►Town or Village �5 Street Address C11 aI �1-e15fa[1s I-osprf01 Manner of Death E Natural Cause El Accident O Homicide O Suicide O Undetermined ri Pending tii Circumstances Investigation 0- ill Medical Certifier Nam U Tale 0 � S+ e_ i ra'lA G ke,Y PA Address tDO 'Rlric St l s k j k ,,::,.,:(city) Certificate ge 1 ens G I Ls Di�tri�cFNi tuber Registe um er Cit Town or Village INO OBurial Date metery,o Cremat ry ['Entombment ��^ �$ ��t Jc � rye V 1 e.0 r.re 1/1Ct 1 O () Addres Cremation I u r5 bu rl� iv Date J Place Removed Z O Removal and/or Held ' and/or Address w` Hold to 0 Date Point of • ` Trans ❑Transportation Shipment iQ by Common Destination Carrier Q Disinterment Date Cemetery Address Q Reinterment Date Cemetery Address Permit Issued to Registration Number Adme of Funeral Homed ,( --Z,L 6 eCt I - rr}e7 iC OO-/) 0 - Chuir(h S- La.Ke, L.uz-e M 12_81-6 Name of Funeral Firm Making Disposition or to Whom ! Remains are Shipped, If Other than Above 2 Address 1Z til C" Permission is hereby granted to dispose of the human emains scribed bove as' dic ted. Date Issued D(a /g j0� Registrar of Vital Statistics llL'�-�� �7 // i J J (signature) District Number 5(��j1 Place ( i ©r G 1 S i15 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: ill Date of Disposition G-)3-/$ Place of Disposition iye V CL, Cr,e,+14_4Ure v m a tLi (address) 0 C0 C (section) !. *� (lot number) (grave number) CI Name of Sexton or Person in Charge of Premises (t& Irmo& 2 ^/ / (please print) 14 Signature Title Crew,a4wry PO54• (over) DOH-1555 (02/2004)