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Mills, Frank NEW YORK STATE DEPARTMENT OF HEALTH - Vital Records Section Burial - Transit Permit , Name First Middle Last Fria/1K- P ll�ii 1 ak Date of Death j Age j If Veteran of U.S. A, rfn ed,Forces, 11, 9 -3 do 1s j 71- War or Dates v lC/m Place of Death Hospital, Institution or City, ow Ne.,,A.)combor Village Street Address 3, 11 ►w, i re..e.Rd Manner of Death `�� Natural Cause 0 Accident 0 Homicide 0 Suicide O Undetermined 0 Pending Circumstances Investigation Medical Certifier Name Title Address fqDeath Certificate Filed District Number Register Number `" City w,o or Village N e.I,)co yy\b ) 5 Date l C etery or Cremat ❑Burial l Y3� ic�e. m �' f � me /°1,/ Addres ,J El Cremation a n5 r Date j Vce Removed 0ElRemoval and/or Held L., and/or Address t� Hold 0 Date Point of NQ Transportation • Shipment a by Common Destination Carrier Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to'q I I� TL(..i'l.Q.(-GC.{ �j')',1✓ Registration Number Name of Funeral Home�(l( ©/jqq Address 63g7 Jt kit )nd 1 a) L_iikt AA/ iZ ' ;3 ' '': Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address : Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 9/ 3Jao IS— Registrar of Vital Statistics .AQ�, � iiiigi (signature) >< District Number /Ssz? Place lG% c.-'/� r ik(-44-41-CfriAJ I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: f W Date of Disposition "III!Ic Place of Disposition —F — �r o+-v ;, (address) LIJ U) >C (section) /jot numberj. (grave number) GName of Sexton or Person in Char e of Premises .t h."' z (please print) W Signature Title ITWAK111-. (over) DOH-1555 (9/98)