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LaPlanche, Christine NEW YORK STATE DEPARTMENT OF HEALTH g3 Z Vital Records Section Burial - Transit Permit iiiiii;ii! Name First Y� Middle Last La u Sex F << Date of Death 1 Age If Veteran of U.S. Armed Forces, N i 3 Z-p15 i g co L War or Dates P- A Place of Death I Hospital, Institution or , .. own or Village \ `(1 Street Address Ps�� obny r vu9-i`ed Ca Manner of Death Natural Cause [ Accident 0 Homicide 0 Suicide Und termined Pending Circumstances Investigation Medical Certifier Name Title ?I Address 04 L3 Nei,,Sena Ave. Alverny A 12 Death Certificate Filed e,4c y 0� District Number RegistGr Number City, Town or Village l 0pC n�, 1 0, 7 Li 3 '3 Date � 1 Cemetery or Crematory, El Burial \�1 2.5 / Z015' f 1YLQ ViPi,) Y 1900- 9,6 Address f \,,,` ::JCremation Q�t..Q. 1S�Uf �jl \2 g1Y Date ' ) Place Removed Q❑Removal and/or Held -• and/or Address = Hold 0 Q Date i Point of NQ Transportation. Shipment 5 by Common Destination - Carrier Disinterment Date Cemetery Address Reinterment Date Cemetery Address ::->3 Permit Issued to _ _ /N4, Registration Number i> Name of Funeral Home _ _ 3/4,C6- K f-�.� iy� 1 1,� � ©ii 3Q Address // // G la's9''f L-TT2�"Y J? 0 oF:2.uS 0 0 ' 1 - /2 ti . Name of Funeral Fytfm Making Disposition or to Whom Remains are Shipped, If Other than Above • Address `' Permissi o is ereby granted to dispose of the human r- ns described above as indicated. '>s Date Issu ) Registrar of Vital Statistics , 0 f\4,0 0' ,e,U,, /( Fe m. iM (signature) iiiiii District Number 10\ Place r 4 s- C)� '�h `©Qsc` I certifythat the remains of the decedent identified above were disposed of in accordance with this permit on: P .1 Date of Disposition jj 117((Y Place of Disposition Full., rem4-oni--- 2 (address) 1JJ . N C (section) (1 t number), (grave number) DName of Sexton or Person-in Charge of Premises • thni 31+10-1 3r (please print) W Signature Title (J71 4 - (over) DOH-1555 (9/98)