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White, Patricia 4- S-4NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section r Burial - Transit Permit Na First Middle • Last ex } �c �r.� _ �L k h A C Y1�41�- Date De th A e If Veteran of U.S. Armed Forces, ID is Ix _ Z i War or Dates J, i.. Place of Death j Hospital, Institutio or )--e&H-R Cityw r Village � � Street Address LA)-e QU At z(s1111-7 Manner of Death 4.7iii Natural Cause ©Accident Homicide Suicide Undetermined Pending Circumstances Investigation Medical Certifier Name Title _ l '.rr,a,r n U i h(-1 to NID Address aLiadaSipl Death rtificate Filed I District Number Register Number y T Citown)r Village LLi-esz_nSb U (L1 1 7-) 1015 Date J metery pr Crema ory El Burial I'h - J lo `� I a- -rJ vI e.,-,J rwa.:4-0 r7 Address / ®Cremation! ( v e-tins ___ __ Date Place Removed 2❑Removal and/or Held and/or Address rg Hold Date Point of N ❑Transportation Shipment a by Common Destination Carrier Disinterment ; Date Cemetery Address Reinterment Date Cemetery Address 1 Permit Issued to Registration Number Name of Funeral Home r ' AG COD--( I C Lk2Lr Address- nB ' r( J� ,t/ )2,ig I lit�1.1 jj ... � Name of Funeral Firm Making Disposition or to Whom W Remains are Shipped. If Other than Above Address Permission is hereby granted to dispose of the human emains described ab as indicated. Date Issued Io--tlo-xtt- Registrar of Vital Statistics '4A &_)b2 '}�'"�, 5�5- (signature) / District Number ? Place jc� � , I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: N W Date of Disposition I)- t 7- r L. Place of Disposition 'i/t p c1:"-e..._} C f. , ak jn'� ►V] 2 (address) W CA (section) ff (lot number) (grave number) aName of Sexton or Pe son in Char a of Premises "rr,.,elk g,,;�,�fe g �_�-- (please print) al Signature LXTitle er'e..,a'wP 1?! • f DOH-1555 (10/89) p. 1 of 2 VS-61