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O'Connor, Carol 1 4-1 3/ NEW YORK STATE DEPARTMENT OF HEALTH � Vital Records Section Burial - Transit Permit "'`:`: Name First rs Middle i, Last Sex WE Date of Death I Age -7 1 If Veteran of U.S. Armed Forces, M o t / I 0 / ao is �f i War or Dates -f Place of Death rr - Hospital, Institutio or C. , Town or Village V�-G_'�5 F�LLS Street Address LE�' ALAS ��©S T A L. Manner of Death nill.P1 Natural Cause 0 Accident D Homicide D Suicide D Undetermined CD Pending q Circumstances Investigation Medical Certifier Name Title � N R.,5-7°P1A E St, tyoy V 7 Address . 1t2 l C cm e I ‘Z.- Qv LE.. %.-3 s e,U Q,A PJ<-v 3$c 4 .. Death Certificate Filed ; District Number Register Number •v:�. G L E N 5 FA L > ; City, Town or Village `-S ? ..51� CI 070 Date / C etery or Crematory El Burial 0 t ! ILA , ..g0\S 4 `^N i! \) .T. E\-► CR t:M ►k-T O R``‘ Address n :: El Cremation 1. v i L R. .e:,racy Qv e l; vJ @�v .'�-‘ i t-- i� o Date i Place Removed D Removal ! and/or Held and/or Address Hold -- 2 Date ; Point of IA 0 Transportation _ Shipment Cl by Common Destination Carrier El Disinterment Date Cemetery Address 0 Renterment Date } Cemetery Address <`: Permit Issued to Registration Number y: Name of Funeral Home Navnard u_ oaken• p-wlercc-I Home, 1 Oi ) 3o `.. Address // Larai-f Gtte (3, , 0UtE.C/)S&Ind ,f kw 9Uc)L- `,1 AY/ 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. - tii Date Issued I j z/i 5* Registrar of Vital Statistics (AD ` : (signature) .'i / .t District Numbers-�C/0/ Place ( e/Z , //S /4ij/ )kvl I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition I Ar/J Place of Disposition . Crim*Po- 1 (address) ',i (section) (lot r tuber) (grave number) AName of Sexton or Person- Charge of Premises ( °i —S=' r- Z (please print) Title c2Fi+ i- Signature , (over) DOH-1555 (9/98)