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Burt, Roy NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit N.. , First Middle Last Sex ©N.1 Crcinri hurt, A/14k- Date of D ath Age If Veteran of U.S`. �rmed Forces, I - 2,9 - 20 lc 6 ct _ War or Dates V le+-ri a✓yl i-r Place • Death Hospital, Institution�'�o_r_ W City, Tow► or Village /(Id I Cu �, � Mtn Street Address I o Dr Manner of Death Natural Cause ❑Accident ❑Homicide ❑Suicide 0 Undetermined ❑Pending Uj Circumstances Investigation W Medical Certifier_ Name 7-- Title CI — Dona Ed IF;turl e Co D1'1Qf,— Address Inle+ , v r Death Certificate Filed District Number Register Number City Tow or Village ), {'I.GLi\ ❑Burial Date ete r Crematory , ❑Entombment �`�'O� �021`1� .1�C °u '""' e -iv vij, Address Cremation �U ,Y1 n i1 �l Date J Place Removed Z ❑Removal and/or Held 2 i=' Hold and/or Address Cl) Date Point of i 1=1 Transportation Shipment L by Common Destination Carrier ❑Disinterment Date Cemetery Address ❑Reinterment Date Cemetery Address Permit Issued to A I Registration Number M Name of Funeral Home 1 I le-- 1Jv�e a( I 1)vryy___ 0111 Address(_- J 7 au7-e RA ) h-y ayiivy /2 c o Name of Funeral Firm Making Disposition or to Whom • Remains are Shipped, If Other than Above Z. Address Cr LEA ` Permission is hereby granted to dispose of the hu n r mains described above as indicated. giii Date Issued \Z\z-\20 t - Registrar of Vital Statistic A 0 0 fLajty..---0-3---- (signature) District Number 0.05 Place Ul_tyliail �k___ I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: E Li Date of Disposition i _i-i-i s Place of Disposition ?n e to s c',,J Cr,,ri 4 4 or. k) n 2 (address) LU Cl) CC (section) (lot number) (grave number) l• Name of Sexton or Person in Ch ,rge of Premises 1 +moiltiy �- to hv(/{ 2 ���, / (please print) I t Signature . Ij Title Cr e:.VAv r., As51 ' (over) DOH-1555 (02/2004)