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Washburn, Anita NEW YORK STATE DEPARTMENT OF HEALTH Sal Vital Records Section Burial - Transit Permit Name First A Middle Lost Se,2c- / ) Date of Death Age If Veteran of U.S. Armed Forces, u / , 0 t`t CI L' War or Dates }- Place o De Hospital, Institution or ECit , own o Village L,..k ' i�,t e r& Street Address C�I l S-ci-. C Ma eath jJ Natural Cause 0 Accident 0 Homicide 0 Suicide ri Undetermined ri Pending W Circumstances Investigation W Medical Certifier Nam Title G }j to -lr lNS•;ay't.a.,, �wAS� AKA-.Ad ess Cucf fce•.. H( ) 13 AI.�,tr Ate, CoIt�t- A!. t I .ti . 1:.- Death Certificate Filed District Number . S Register Number I Cit ow .r Village L L,,4_ u z c,,, - 0 Burial Date / Cemetery or Cr atory /' �K S / g/ �©/`C 2 c V`c,,•�,J G�fr. '4z.v 0 Entombment Address SiCremation ��cis,v.r N:T Date 3 ' Place Removed Z❑Removal and/or Held and/or Address N Hold CD 0 Date Point of 0 Transportation Shipment G by Common Destination Carrier Disinterment Date Cemetery Address 0 Reinterment Date Cemetery Address Permit Issued to _- - Registration Number m. Name of Funeral Home -- ` 1 ,.,,rc met k (. I-4 .', -c.._ 0 0 4,-54 Address 7 5 ke r M 0,- /4Vk• ) C,,. 0,`t" 1 a% ?2__ Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address CC fCL ail 1Permission is hereby granted to dispose of the human r a' s d cri d above ' dicated. - Date Issued j$ /g- ii Registrar of Vital Statistics t..G,Ic.i 7 ignatur / /_ District Number `�- Place c�� V / / l I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: 1/1 Date of Disposition f;?fI1S11K Place of Disposition ,IL Cu*vie to" (address) lj Cr (section) ,j (lot number) (grave number) 0 Name of Sexton or Person in Charge of Premises 1:0-0- St' it / (please print) Signature •./�J.�.� Title Cit/CNI (over) DOH-1555 (02/2004)