Prefontaine, Joseph NEW YORK STATE DEPARTMENT OF HEALTH '
Vital Records Section Burial - Transit Permit
Name Fi iddl Sex
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Date of Death el �+ / Age. If Veteran of U.S. ArmedtFprces,
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1- P of Death f Hospital, Institution o /
Z itt-Town or Village -Ph-} -r �" Street Address Ti
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«' -fvranner of Death Undetermined Pending
Q'I�atural Cause �Accident �Homicide �Suicide � �
Circumstances Investigation
tu Medical Certifier Name Title
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Addres R Ram 2-, --
Death Certificate Filed District Numbe Register mb
Ci Town or Village �_�`
❑Burial Date Cl D Zc lY Cemef3ry o . .�
❑Entombment r !/
Address Po1 ., 9
�emation �-( �V��
Date Place Removed
3 ❑Removal and/or Held
Y. and/or Address
F= Hold
f/
0 Date Point of
OS El Transportation Shipment
ES by Common Destination
Carrier
0 Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration umber
Name of Funeral Home Pi P, 1'l/k-- ri..44-iP-A-t-gi've-- d/0 76
Address (.;6 fli Ai Si-
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Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
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"' Permission is hereb granted to dispose of the human remains de r'be a ve ndicated.
Date Issued 07 2 / /4/Registrar of Vital Statistics ' L�
(signature)
District Number 4 0 Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k
lr� Date of Disposition -30'W Place of Disposition IQI.I V& 1 CAM tzy
2 (address)
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C (section) lot n ber) ., (grave number)
Name of Sexton P in Charge of Premises a
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Signature Title ekeyer' e'G
(over)
DOH-1555 (02/2004) •