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Holcomb, Stanley NEW YORK STATE DEPARTMENT OF HEALTH ' ' I Vital Records Section Burial - TransitPermit Name First Middle Last Sex 5 0 Y pkvlb D r"g N1 Date of Death Age If Veteran of U.S. Armed Forces 1-/- D -7-0 a 5-�-- War or Dates j-, Place • Death Hospital, Institution or City, o • 4Village C 0 L J'iAGKi Street Address ,Zb� �� 0 Manner of Death C atural Cause Accident Homicide �Suicide C Undetermined �Pending ua Circumstances Investigation la Medical Certifier Name Ti IA lilt CA4A( LI.oIL.n Ropint-- :„.:::. Address 7A' o,rs .1- , ,Izo_, A 1:-2-Yr a Death Certificate Filed /t District Number �j L� Register4umber Cit Tow r Village �O J'A c k) i_I s 1 / 7 ❑BUrial Date ete r irAory/)/ Afire J oiiIz- 8—`7-a1 Y1 V (. i 0 tombment Address 5 � >/ f Cremation Z I G to -IC rLp�` l D 1jS$vh-y_ 1 1 — 1/ Date Place Removed Removal and/or Held and/or Address 1 Hold ;l C Date Point of Transportation Shipment 6 by Common Destination Carrier Date Cemetery Address " 0 Disinterment Q Reinterment Date Cemetery Address > Permit Issued to y�� J Registration Number NI Name of Funeral Home 1 9, �j+-MEdZ- u tJ V �`ei O A4 e- 0 1 p-1 E) >; Address l 36 VtliN.,A) %- - ,C© , 64,,v em , A) V b Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address al " Permission is hereby granted to dispose of the human remains described ab ve as i icated. f Date Issued 12-1-7- I ( Registrar of Vital Statistics (signature) . District Number I q Jy Place . D,t S'p,Cvl�� /Av) 7 / I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: 11.4 Date of Disposition IL/B)i- Place of Disposition ,U.,.� to N.. a (address) P) (section) Af lot numbe (grave number) Name of Sexton or Person in Charge of remises C'tr1j " fit (pIase �print) 41. Signature L l Title frefrvre ►� (over) . DOH-1555 (02/2004)