Benson, Donna NEW YORK STATE DEPARTMENT OF HEALTH ' 563
Vital Records Section �- N Burial - Trar!, Permit
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iiii Name First Middle Last Sex
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Date of Death ~�I� r IS Age I If Veteran of U.S. Armed Forces,
/ 14 Q i War or Dates `
Place of Death I Hospital, Institution or
City, Town or Village GZ...Gi-- S rAt_ s ! Street Address ()LE -Gt,..E.r-DS FAu--S ucs' 1 r A L
Manner of Death FA Natural Cause D Accident ❑Homicide D Suicide 0 Undetermined Pending
ijj Circumstances Investigation
itif2Medical Certifier Name Title
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Address
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Death Certificate Filed I District Number R s Number
City, Town or Village L Le,r-'5 CAL-L-S ! - 0 1 l �
Date / 93 / �� I� � �metery or Crematory
❑Burial 1 ! I,- E.. �, E. `J C
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Address
)Cremation
Date i Place Removed
0❑Removal and/or Held
-- and/or --
1•;,; Address
a Hold
0- Date - -- Point of
N 0 Transportation i j Shipment
a by Common Destination
Carrier
0 Disinterment Date j Cemetery Address
n Reinterment Date Cemetery Address
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Permit Issued to k Registration Number
Name of Funeral Home ZCZ �� � e cc� �1UMe I Qi) . ()
1.1 Address
1/ Lara.y,-ttc of. , bc,t_cc.nsbury i 1Ue,w Lj0c) / O
"#`��.-, Name of Funeral Firm Making Disposition or to Whom
LE Remains are Shipped, If Other than Above
'C Address
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Permission is hereby granted to dispose of the human r ains scribed a ove as indi • - ,.
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Date Issued / .50/3" Registrar of Vital Statistics �'� �-��/ / 2/LC
i- District Number �4�i Place � �
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I certify that the remains of the decedent identified above w e disposed of in accordance ith this permit on:
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iii Date of Disposition /"D.5-IS Place of Disposition (Rn t/,'e(4) C re is,¢'G r,/t/n,,
2 (address)
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cc cti�,L(se (lot n�ber) (grave number)
Name of Sexton or Person in Charge o Premises i'w, q - 45Pu lyetk
Z (please print)
4 Signature4 Title CrefrC.,apt 114 / •
(over)
DOH-1555 (9/98)