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Adams, Annette co NEW YORK STATE DEPARTMENT OF HEALTH 4 - - lk Vital Records Section Burial - Transit Permit Narix First Middle Last Sex ►)NBCue- .U1 Ada ni-t ola L Date of Death Age rr���, If Veteran of U.S. rmed Forces, I -.Q•-c)D I J (av War or Dates jJO } . Place,o Death Hospital, Institution or 6-,r wCity(To�or Village iD►1 LLB sZ�_ Street Address IL", ' CI C Y\5 )< L}i O Manner of Death Natural use ❑Accident ❑Homicide El Suicide ❑Undetermined ❑Pending IW '�°'� Circumstances Investiga ion WMedical Certifier i Name /Title Address �� ? 0 Lb(X i L©n L <Q , , 7 Death Certificate Filed p ,� District Numb Register Number City, Town or Village C.--t)f (% ,, _:, . 2 05(n 2- ❑Burial Date + N} metery or Cremator ['Entombment O l I 3 d-- � l S t , n C. 4` I c i&) L C t)� �1'2: Addres \,, "Cremation ri. 0.-e •t`1Sbli1-t t;{ Nc Date • J Plac Removed . Z❑Removal and/or Held Ng and/or Address H Hold t 0 Date Point of 0 Transportation Shipment 5 by Common Destination Carrier ❑Disinterment Date Cemetery Address ❑Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home 1\.,i1 t I I — -Cyr-et ( --0 dye 0 1 i q Address '` Ind I« l e1 i 2SLI Name of Funeral Firm Making Disposition or to Whom I Remains are Shipped, If Other than Above Address cr fa fl" Permission is ere y granted to dispose of the human rxnains described abo e as i dicated. s ' Date Issued ( �3 15 Registrar of Vital Statistics itt _ )1 (sign ture) MO District Number 0s05./0 Place I© 1,C1)41 1 ate J i I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: iti Date of Disposition ( /7(j(11j'• Place of Disposition &L (,..,tifor (address) in CO C (section) (lot number) (grave number) p j Name of Sexton or Person in Charge of Premises -.0 Zilease print) Signature - Title l'Cistmiv (over) DOH-1555 (02/2004)