Duve, John I . I
NEW YORK STATE DEPARTMENT OF HEALTH Burlal - Tr it
Permit
Vital Records Section
Name First Middle Last Sex
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Date ofDeath Age if Veteran of IJ.S.Armed Forces,
War or Dates
Z Place of Death Hospital, institution r
t},{ -Gtty,Town-or-Vii p Street Address
4 Manner of Death
Natural Cause Accident Homicide Suicide Undetermined en ing
W Circumstances Investigation
Iii Medical Certifier Name -� Title
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iliaAddress
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Death Certificate Filed District Num� r/ Register Number
E -Gity,Town afiHage o REAt� -/5 Z 20
Date �i77:7.
oratory ,gy Ke.m
El Burial
n/ remation Address C ` Q
Z .. ::.....Date.:.::. L. :.:..c .:Lt AkE late Remo ed ). c- : 1.-1),.... # a t�o i-4-- :..
o ❑ Removal and/or Held
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a. Date P.............................
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cn El Transportation by Shipment
pCommon Carrier ......:..:::.:.:..::.......:..::::::...:...:.:............
Destination
0 Disinterment
Date Cemetery Address
0 Reinterment
Date Cemetery Address
Permit Issued to • Registration Number
Name of Funeral Firm...... �..... N�rA (Tz ' R. QX\L ii.)...! -r ►�
Address
t:: Name of Funeral Firm Making Disposition or to Whom
j: Remains are Shipped, If Other than Above
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Permission Is hereby granted f!�(f✓granted to dispose of the human remains described above as Indicated.
Date Issued .31,2 ) 1 Registrar of Vita!Statist cs 17). ,.
(sig ture)
District Number Li (OL.- Place // /fLdJOr) 41. ioLt ) off''ofeils Fouts g- J2SQ3
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
F-
Z Date of Disposition 3-4r-Zo iz Place of Disposition (e+yr2.iJ 1.Ec....) Cf. 2+,1&`4-04.-=0141
w
5 (address)
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tX (section) (lot number) (grave number)
pName of Sexton or Person in Charg f Premises ( tfyrt O#L/ tlwneltC-
Z --- (please print)
w Signature 4
Title Cr@„-tk care, 1Ass-/.
DOH-1555 (10/89) p. 1 of 2 VS-61