Mosher, Paul NEW YORK STATE DEPARTMENT OF HEALTH` ,.--A 1
Vital Records Section s Burial - Transit Permit
Name First addle Last Sex
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Date of Death / Age /•/ If Veteran of U.S. Aredd Forces,
`�// / a o,y-- (� ce War or Dates
of Death _ r ,J-lospital, Institution or
z Jr own or Village, -,r..x , Street Address ar -71z. y .,
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a :nner of DeathLii Natural CWise Accident 0 Homicide n Suicide Undermined/ J Pending
Circumstances Investigation
tu Medical Certifier Na 1 : Title
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Certificate Filed fi District Number r J Register Number
,„,,_i, .s ,,r ,,,
it , own or Village _c r1--4 r�/f' `f$D
Burial Date g/1 0 0, (/ Cemetery or Crematory
,li e vTc._,.., Kic,...1- 7, ......------
['Entombment Address
NCremation A, sr
Date ' Place Removed
Removal and/or Held
and/or Address
i= Hold
O Date Point of
ti0 Transportation Shipment
Et by Common Destination
Bi Carrier
Q Disinterment Date , Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to _ Registration Number
Name of Funeral Home „1,n,rc I unUt L. 4^4-/ l-c- 00 `t ti
Address
S_I er Ko-4,- /'1-Ve- r..t- NI- u<6)L
Name of Funeral Firm Making Disposition or to Whom
} Remains are Shipped, If Other than Above
• Address
a' Permission is hereby granted to dispose of the human remains sc ' ed aVve indicated.
il Date Issued 00 /is Registrar of Vital Statistics �.--_,
(signature)
District Number `t Sd L Place CK -�
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;::.>;.' I certify that the remains of the decedent identified above we dispose of in J cordance with this permit on:
1
ILI Date of Disposition I itf iS Place of Disposition ZstU, ' ew 00..
2 (address)
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U,
M (section) (1o.umber)r J (grave number)
O Name of Sexton or Person in Charge of Premises G 1r., SL 41 1
+fir o (p ase print)
Signature 4 -'lr— Title (IZ I }1'( .
(over)
DOH-1555 (02/2004)