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Conover, Robert NEW YORK STATE DEPARTMENT OF HEALT` t ! - 31 Vital Records Section Burial - Transit Permit N First Middle Last Sex care r t C'ov)0vrn-- M a1e_ Date of Death a If Veteran of U.S. Armed Forces, a-a Co - a D / 5 War or Dates \cl 6 3 (q 5 (0 14 Place of Death 'Hospital, �/""Institutio r City, own r Village j p r L-a_i''c� Street Address f v r Ll lJI 0Ctr, Manner of Death g Natur I Cause El Accident ❑Homicide ❑Suicide Undetermined ❑Pending JAICircumstances Investigation LL Medical Certifier Name Title v ' , )---e- M 1b �� Address P1QCidt / , Ni Death Certificate Filed I District Nu ber Register Number City, ow">or Village I La /�.. • /(off ❑Burial Date I�1 metery or Cremato ❑Entombment 0?. — Q:7 1 I e V 1 r ( l_,. •� i�'C a -fOilli igiiAddrem '<> (Cremation �,y�S (u Date J Place Removed ❑Removal and/or Held and/or Address ta'— Hold 414 Date Point of ❑Transportation Shipment 0 by Common Destination Carrier El Disinterment Date Cemetery Address El Renterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M t I or Vle_,l'cl.` �-.-c yLs2___, (0 i I q 3 '«> Address 633 33 a 4-e aft9- " tc.) i Ac Ai\ 1,fl_ko A,V I 2.e+-cD, Name of Funeral Firm Making Disposition or to Whom i:] : Remains are Shipped, If Other than Above Address li in Permission is h reb granted to dispose of the human rem s described above indicated. Date Issued ©Z (a7 a©1- Registrar of Vital Statistic /-/_0_ __� ,_„ (signature) District Number )(p-2-0 Place 1 toLke__ I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: di Date of Disposition 3)311 c" Place of Disposition ,,,, ,.�. Ai (address) C CC (section) 4 (lot umber) (grave number) et Name of Sexton or Person i Charg of Premises 2 `,y (please print) 4Signature Title 8/0"►tloit (over) DOH-1555 (02/2004)