Hurtado, David NEW YORK STATE DEPARTMENT OF HEALTH ' ' 3 0 2
Vital Records Section Burial - Transit Permit
Vii Name Fir Middle Last Sex
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Date of Death/ r Age j If Veteran of U.S. Armed Forces)
l*_ 1-i 9 I i-r 3 cf> 1 War or Dates ,d/,(g
Place ath / i institution or
Ci , Town r Village t k97C ir C c e/ C t r , 1 CAC-P s r 7 J -P 7
Manner of Death❑Natural Cause ❑Accident ❑Homicide NSuicide EI Undetermined Pending
AN Circumstances Investigation
It Medical Certifier Name Title
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:" Address
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ai Death C rtificate Filed District Number / Register Number
I City Tow r Village /..ole �CO/Z c O ; (
Date f I Cemetery Cre .�
:: ❑Burial If/2-/ , 1 JU)‘n-O
Address �^
i�cremation Q 0 /y2/0 S'0 U trt(A. Q ti /U v
Date ' Place Removed
0 Removal _I and/or Held
rn and/or Address
5-3 Hold
0 Date Point of
Q Transportation i _ j Shipment
a by Common Destination
Carrier
Date i Cemetery Address
C Disinterment
Renterment Date Cemetery Address
"ill Permit Issued to Registration Number
;iaii. Name of Funeral Home Maynard b; &titer FL/lercz/ Home_ 01 ) 30
ii t' Address 1j Lafa. CIC S&J(cr L r 1o�
�-/ c c e_cn y /vew /v I� b' y
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' Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
£t Permission is hereby granted to dispose of the human remains described ab as indicated.
<_N Date Issued �"`� I --( S Registrar of Vital Statistics 6
(signature
`L` District Number S�P Ss ( Place t.,0 jN k&
I certify that the remains of the decedent identified above were disposed of in accordance with this perm on:
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ii Date of Disposition 4/2'I/}�' Place of Disposition AZAL Cam--
a (address)
w
CC (section) of num r) (grave number)
Name of Sexton or Person n Charge of PremisesCi i 14 Lv�f.,-
Z (please print)
U: Signature Title cizT r
(over)
DOH-1555 (9/98)