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Ovitt, Patricia NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit N e First Middle Last Sex Dtth' c to M av t 4 Feisicat 10 of Death Age If Veteran of U.S. Armed Forces, q-Q -IS -70 War or Dates no Place of Death Hospital, Institution or 5 CityCow9 r Village Co r i r‘ Street Address 51- Siewax j br RA W Manner of Death Natural Cause ❑Accident ❑Homicide El Suicide 1-1 Undetermined ❑Pending Circumstances Investigation W Medical Certifier Name Title 0 Su:SGLr, bo r-sp,i M b Address We St fled t C2a U r )"`� Re5 is e Death Certificate Filed District Number g r Number City, ow or Village Co r „NA-eN ❑Burial Date Qemete or Crematory 1 ['Entombmentt CI- 1©--/5 'ne. V 1 F`o Cron ' D ej Address ,d�.^..� C IA Cremation iL.n5lak rq Date Place Removed Z Removal and/or Held 2❑and/or Address�; In Hold 0 Date Point of ❑Transportation Shipment G by Common Destination Carrier El Disinterment Date Cemetery Address ❑Reinterment Date Cemetery Address _ Permit Issued to Registration Number Name of Funeral Hom X-r' F-�� o .1...\_,Atp�I nc Oc 1) Address cgt NIA%C:h St•- La-k_s_. Lik 2-e-r-it)-- NY /alio Name of Funeral Firm Making Disposition or to Whom I; Remains are Shipped, If Other than Above 2 Address Iif P? Permission is hereby granted to dispose of the human described a_bov s indicated. Date Issued g/U/fc Registrar of Vital Statistics ____A_ 6-t � signature) District Number SS3 Place / ' y - )U i ' I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: 2 � lit Date of Disposition 1Jiujrs Place of Disposition i„aUt-.> C, -<fioc;,,„.,. (address) Ui C4 1C (section) (lot number)) (grave number) 0 or Name of Sexton or Person in Charge of Premises L 41 - J .42 please print) Signature Title tiZ F,41 /4. (over) DOH-1555 (02/2004)