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Garry, Juanita NEW YORK STATE DEPARTMENT OF HEALTH ; �1 Vital Records Section Burial - Transit Permit ? Name First 1 Middle Last Sex Date of I Age If Veteran of LYS. Armed Forces, 9.--$- Zo a, g7 War or Dates � .,._._ ., Place of Death ; Hospital, Institution or ,� (+a Town or Village G J t r f (s Street Address G 5 -g- I I€ I lily fla 1 Manner of Death 61-71 Natural Cause Q Accident 0 Homicide 0 Suicide Undetermined ❑Pending '-la Circumstances Investigation 'W Medical Certifier _ Name l - Title 0 _C. : . L Gt , so,,.. -t t. _ Address .., G4..L4.. i t L.) b. k)\- Death Certificate Filed i District Nu Register (`CiiTown or Village C)_,V).`5 fa ( IS f) 1 I Date metery r Crematory ❑Burial 1,- i D-2© 1� �_.L aC_� Address ►l Cremationl 0.u et. Date Pace Removed 0❑Removal _, . _�m.,_ and/or Held and/or Address Hold 0 Date Point of N❑Transportation ' Shipment a by Common Destination Carrier D Cemetery Address Disinterment Date Date Cemetery Address 0 Reinterment Permit Issued to Registration Number 'i Name of Funeral Home 1r_Aze.r -1't,C ri-(-& 1 I n£- ©0 Address 9- 1" Cht,u-ch 5 l ' Name of Funeral Firm Making Disposition or to Whom "" Remains are Shipped. If Other than Above 144 Address Permission is hereby granted to dispose of the human remains described above as indicated. `. ,i Date Issued ; 24 10117 Registrar of Vital Statistics C/VCA-A-t-r. _(.A).A- U • (signature) { District Number oO/ Place 6-/e 4f fe i /ty /sr'/ I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: f- ,,� DILIate of Disposition i2slh t Place of Disposition 1 at 1,:. C &i_ 2 (address) W N Ce (section) ,'j (lot number) ,i� (grave number) CName of Sexton or Person in Charge of Premises 2 (please print) W Signature dtb,_ _jz.- -- Title C Ea m f}T0t DOH-1555 (10/89) p. 1 of 2 VS-61