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Lieber, Christina NEW YORK STATE DEPARTMENT OF HEALTH 3 Vital Records Section Burial - Transit Permit Name First Middle Last Sex F ig..= C Rc?.._ks,)NA. \ -c_- ucdE�. <; Date of De th 1 I Age 1 If Veteran of U.S. Armed Forces, ©`-( ) )S i (S).5 Go i War or Dates i Place of Death I Hospital. Institution or City,Town or Village G CZPcJN3 i t-1-E f Street Address ` - cJ c to . K,\Q t 'z- -V 2S i J i, Manner of Death El Natural Cause 0 Accident fl Homicide D Suicide n Undetermined a Pending Circumstances Investigation IV Medical Certifier Name o Title Ivy = 5�. r Address Of l0O cANZit._. S Gt. o's cAL - I SO 1 ``- Death Certificate Filed District Number Register Number •Y•� City, Town or Village G%Lisa-,'‘LL i= ; LJ Burial Date j C et br C amatory / clo Address Cremation Qt_.''Au i-1. �� O u C.E.h)S Q ti v R-\l j _ Date Place Removed 0❑Removal and/or Held N and/or Address Hold 0 Date Point of et! ►Transportation j Shipment t by Common Destination Carrier Q Disinterment Date Cemetery Address Reinterment Date j Cemetery Address <`=: Permit Issued to � / 'Baker- I Registration Number f Name of Funeral Home!l t- f rc1 _ Faller c.i J Jame. el i .() :0 Address ll La: a., et e 3f. , &c utns .r.v, jUi✓w Vac)t la?GL %} Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above ea Address MI Permission is h eb granted to dispose of the human Tema- s descri ab• i, as indicated. t Date Issued 2/ /„� Registrar of Vital Statistics / . ' `1--`-- �J OO �f(signature)//�-/_/// 't: 7 '/� c (/ (Y /V :`_: District Number 5 ,�� Place ,1 I//�� -all Ark I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: F; C Date of Disposition q/niir Place of Disposition _ZV.-3 C I (address) !t} lr (section) (lot numb) (grave number) ° Name of Sexton or Person in Charge of Premises .� r,,v --- 4 4 (please print) Signature Title oil e (over) DOH-1555 (9/98)