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Avona, Leonard NEW YORK STATE DEPARTMENT OF HEALTH f L�3$ Vital Records Section � Burial - Transit Permit M ; Name First Middle Last [ Sex - A lig L.e©r\arri PC J Dna r L . .,ili Date of Death I Age 1 If Veteran of U.S. Armed Forces, :; ©c 6L Il 2-015 CV.G I War or Dates 1 q 91 - 1 g1-15 '--PPlace of Death I Hospital, Institution or cl.Ci 1:+-y City own r Village Street Address p W-1+ ,11-}- gManner of Death 16.1.2 Natural Cause n Accident ❑Homicide Suicide D Undetermined D Pending ill Circumstances Investigation .I Medical Certifier Name Title a RoI\\Y\ Socolt 1\1� `- Address iiia Death Certificate Filed �rD ict�uber ReY i ter/Number City, Town or Village I " m 1 Date I Cemetery or Crematory ❑Burial Cck ) Q2 ) a0 Address Pine �'rema cY Cremation Q W10 ►1Sblt r t✓l 1_,lv 7 1 Z o`�- Date I Place Removed ❑Removal and/or Held -- and/or Address }= Hold to a Date _ -- r-- —— uinty of os n Transportation i _— j Shipment p by Common Destination Carrier �j Disinterment Date i Cemetery Address %:: n Reinterment Date Cemetery Address Permit Issued to Registration Number ' ZR 0 Name of Funeral Home 6 TU /IoM�ref-a/ 0/ ) 30 Address `j / ar itName of Funeral Firm Making Disposition or to Whom " Remains are Shipped, If Other than Above 14 Address ei :<.: Permission is hereby granted to dispose of the hum r mains described above as indicated. 41 I Date Issue Q 1. � 1 3- �� I� Registrar of Vital Statistic � RR (sig ture) '': District Number -�X9 fl Place I 0 (..3__n U Lk� h f- I certify that the remains of the decedent identified above were disposed of in acconc with this permit on: it Date of Disposition R13I(r Place of Disposition gaVot) r> ar., MI (address) CD CC (section) ot.number)c• (grave number) 0 Name of Sexton or Person in Charge of Premises �, 3l4l - Z d 1 (please print) W Signature Title i itrolifik (over) DOH-1555 (9/98)