Russell, C NEW YORK STATE DEPARTMENT OF HEALTki \ �Zt
Vital Records Section - ,,, . Burial - Transit Permit
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..„ Name First Mc.1. e _ Wt S/ "`/
il✓�t r` df 5 ( e-
ffiii Date of Death A e If Veteran of U.S. Armed Forces,
�C - Q� . � War or,Dates
Place of Death Hospital, Institution or_
• City, own-sr Village &i-2//1 A. Street Address .� �j_j , �?.k / 0
Manner o Death17156pislatural Cause El Accident 1=IHomicide Suicide El Undetermined 0 Pending
Circumstances Investigation
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Medical rtifier1,A.,, me Title
e0Y _ 'f,gk i ,, , 1
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Address J_ •
Death Certificate Flied j (53 Dis i Nu_mber Register Number
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City, ow` r Village r J/) / (>
Datetery or Crema ry
ii ❑Burial 6 `/6 --/5 //).v/e4) .��-61-'
AEIck,ess
Cremation C-CkdeentShtcr/y II
FDate Place Removed
0 Removal and/or Held
and/or Address
a Hold
O Date Point of
N ElTransportation Shipment
a by Common Destination
Carrier
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Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to C � � � Registration
`': Name of Funeral Home /1S,'Yw r� �G h d/A Y e- 2G 06
iiiiiii Addres,7 /�
in `ff i__F/e//'// --vim -Vie ( i°-1 s1,"1, . 1� 12—CC-2.--2--
iiiiiiiiName of Funeral Firm Mak n Dis c(sition or to
9 P y ��
Remains are Shipped, If Other than Above e, n fe.�Lf _, ta.4-,. w C _
• Address-7,.>fri,„,..-_, L
• Permission is hereby granted to dispose of the human lams scribed a ve indicated.
Mii Date Issued DG `69-/J Registrar of Vital Statistic
(sig ature)
`' District Number 443 j Place /''e ram_
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
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W Date of Disposition (,/1c!1c Place of Disposition 'fi:,tLa 6-146 .-
2 (address)
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(/)
CC (section) 4(lat number (grave number)
GName of Sexton or Person in Charge of Premises L ^�«9PLthr4t1
z .4A (please print)
10 Signature G'l� Title lMrpik.
(over)
DOH-1555 (9/98)