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White, Lester NEW YORK STATE DEPARTMENT OF HEALTH( cr Vital Records section Burial - Transit Permit Name First Mpiddle Last Sex L25 ec' e-ecr-J L,Jkn:k_ M ` ; Date f Depth Age i If Veteran of U.S. Armed Forces, --I ED (a ( il4 LA _ War or Dates iR 4k.- \55.4 1 Place of Death Hospital. Institution or Cit�r, Town or Village ���r� Cc41S Street Address C.,L•e_^S tFeAn 4aos e; c I Manner of Death l��1 Undetermined Pending { ©Natural Cause t l Accident �Homicide �Suicide � � 9 Circumstances Investigation Medical Certifier Name Title P c-, c_,0. IV.) ec Iv.(e Address _.__._ :f: tar r'((-- E'Ck, C.vee -mob"' ►.`l_ VIg°t� }i Death Certificate Filed ct Numbers`" �gister u r ig, City, Town or Vi1Ia9e 61/ Date 1 Cemetery or Crematory ❑ hi Burial i 3 / oao\y I Vtt� Lrt.„„e. Address to Cremation ( vc.ce,r % Q0,ct r sb'-'r- c❑ r � l'a.`- `SO� —J Date ' Place Removed Removal 1 and/or Held El! and/or Address - _ CO Hold 0 J Date T Point of a[]Transportation 1 Shipment a by Common Destination Carrier Q Disinterment Date j Cemetery Address Reinterment Date Cemetery Address Permit Issued to xf.� ,1 � Registration Number Name of Funeral Home HCu/nard I., �Q./�ec Junelcr..l home 011 3( Address ,, L aT a-yR#c 3t. , bu sb ry , 1V uo %/k- l a Rvy W. Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above __.. _.___�. Address Permission is hereby,granted to dispose of the human remains ve i dicated. Date issued la/29/ //V Registrar of Vital Statistics >y (signature) y District Number o/ Place _ 15/ed,?jf-a4 WK/gam( I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: f T J FDate of Disposition [1 /3/I l Place of Disposition '•we J dr+ C 110...• (address) Il! CIO 'IX (section) "(lot nu ) (grave number) gName of Sexton or Person in Charge of Premises j4t Z. (please print) i Signature_ Title C Ora (over) DOH-1555 (9/98)