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Mitchell, William q21 NEW YORK STATE DEPARTMENT OF HEALTH Burial Transit Permit Vital Rtcrds Section <'' Name First ��,�\ ` Middle Last I`�•r► 1 1 Sex y l r 1;_c r l l !`� `' Date of Death 1/y'I^` Age I if Veteran of U.S. Armed Forces, '1 Li ZI l 1 War or Dates I 'V73- 154 ace of Death Hospital, Institution orI�lI own or Viltage �� 1 treet Address G 1f2nS F-41)5- - i Tc anner of Death Natural Cause n Accident fl Homicide Suicide fl Undetermined 0 Penbling Circumstances Investigation Medical CertifierIli Name Title in ot‘nCeS 'S011 ; 01eV P�y )c;cAr) ! Address ILL ett rey I�o ��-�ts�.s �a11S i N 7 r�8o1 Death Certificate Filed District Nurrlber , 1 Register Number1�^ zci ; t;t , Town or Village ��\ lc ,J �� i l� �1 Date i Cemetery or Crematory ' " ::` 11 Burial 1 Z l 0 i / �i►�LQ V i 11�� C� e Yt'�lt 4-0 Address Cremation Qum r Sbttr — Y2 00 Date I Place Removed 2❑Removal I and/or Heid In and/or Address — — —_�__-- 0 Hold 0 Date ; Point of N0 Transportation I Shipment p by Common Destination Carrier D Disinterment Date Cemetery Address r n Reinterment Date Cemetery Address • Permit Issued toQx�T ` Registration Number >I_ Name of Funeral Home fuj?e(CL r//ome } Of c Address // La-Fa-W./WC • , ( LtELOSbt-ir t PI Name of Funeral Firm Making Disposition or to Whom Si Remains are Shipped, if Other than Above j Address =<:> Permission is hereby granted to dispose of the human remains des ribed ab ve as indi ted. Date Issued 1 - Registrar of Vital Statistics (signat e) District Number 6—(0 / Place Z I certify that the remains of the decedent identified above were disposed of in accordance with thi permit on: i"- E Date of Disposition 12-3©-I S Place of Disposition Pi)-)e_ (f;eit.) Grp a14z 7 w (address) rn EC (section) t number) (grave number) Name of Sexton or erson in Charge of Premises �k./,G £ -wi4.,G�e Z (please print) Signature Title Cram 4.441 1 (over) DOH-1555 (9/98)