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Potter, Philip NEW YORK STATE DEPARTMENT OF HEALTH r. 141. # 5-2 y Vit al al Records Section Burial - Transit Permit '>: Name First Middle Last I Sex M _ 1 ' p Almon © r >: Date of Death ► ' 1 Age If Veteran of U.S. Armed Forces, N O� 113 ,a6i i ' 151 War or DatesA -1 Place of Qtath i Hospital, Institution or uu _ City,�own r Village QUe.P!(15biAci ! Street Address -1`J I.-aue_ti-Manner of Death X Natural Cause Q Accident 0 Homicide 0 Suicide Q Undetermined 0 Pending Circumstances Investigation Medical Certifier Name Title Day eqsne Soar.,rxt1;)n V10 Address Death Certificate Filed �q Di tctlumber aster Number ,' Cit Village LY+.t,Q:r ilsb(.,�r) 1 1 Date On ?L ) a Cemjetery or Crematory ❑Burial 1 � 1 - . 01 - _ T (1L 1t t�- —���'� y -j a Cremation r Address a C) _LA-41_11.th,l-try_ JO. j Place Removed Z Date Removal and/or Held F�- and/or Address Hold I • 2 : Date • ?nt of N, Transportation Shipment a by Common [-Destination Carrier � Disinterment Date �- Cemetery Address 0 Reinterment Date Cemetery Address Permit Issued to j Registration Number Name of Funeral Home t tyn0'CI rxX er }-L ner(r-1 / ame. , CI ) 3l`; Address / ar { , II Lcz Lc-rc r 1. . & ui s ztcj , A v e_w VD!-X J 67041il- 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 described a e as indicated. gP < ; Date Issued c1 l3' Registrar of Vital Statistics 4G‘, OA., IZ��.. :13 (sign ure) i District Number \:l9 C 1Th Place _ / Cj & c Vr __--.._ I certify that the remains of the decedent identified above were disposed of in accor ance w h this permit on: i- F Date of Disposition fii1t Ij t Place of Disposition red-i ( 2 (address) CC (section) i (lot number (grave number) flName of Sexton or Person in Charge of Premises it.r: \y nt4 Z (please print) ill Signature 1- 4Title Chtiqiig0 - 'overt DOH 1555 (9/98