Paustian, Lucille r 'f
NEW YORK STATE DEPARTMENT OF HEALTH if '2 9
Vital Records Section Burial - Transit Permit
Name first jj
Middle Last Sex ook
Ag
Date o Deat Age�+ If Veteran o U.S. ArmedForces
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O 7 War or Dates N
j Place of ea h Hospital, Institution or
W City, Town or Village .CC.zi& 474�,~- Street Address e"SS �� C '`
O Manner of Death JJ Natural Cause ❑Accident ❑Homicide ❑Suicide ElUndetermined ❑Pending
tit Circumstances Investigation
ig Medical Certifier Nam& / Title
Ad ress
Death Certificate Filed District Number Register Number
City, Town or Village ,e-ZZ-�,6r irlv44-iJ 3--•S4'Z .
❑Burial Date Cemery or Crematory
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;;:;:;❑Entombment Address
l£remation Qc,�c/ ✓,z j ��
Date ' IP ace Removed
g❑Removal and/or Held
and/or Address
I= Hold
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0 Date Point of
0 Li Transportation Shipment
• by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
<: Permit Issued to Registration Number
Name of Funeral Home /dw4,4,eI ,C_ Z---- (/ ry vz�Lv1�, /v4 QS/9
Address // _7
Name of Funeral Firm Making Dispo its ion or to Whom
• Remains are Shipped, If Other than Above
;; Address
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` Permission is hereby granted to dispose of the hu emain described above as indicated.
Date Issued // z/c— Registrar of Vital Statistics
',,/ �"(signature)
District Number /55d_ Place �dwn �2C }�w'✓c�.¢/1_
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Zr`:::
ILI Date of Disposition r/0/6" Place of Disposition ZIL 61440C iv....
(address)
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fil
CC (section) (lot number) (grave number)
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Name of Sexton or Person in Ch rge of Premises firoj i.-, SL"i'""1
2 (please print)
Ili A
si Signature Title CAW 1DIL
(over)
DOH-1555 (02/2004)