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O'Brien, Catherine NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Nagle First Middle Last Sex crtt er 1 ne. L . 0 Or 1 e-►'1 F-ma k- Date of Death , I Ag If Veteran of U.S. Armed Forces, i U- -- 2.)151 T War or Dates i\J n Place of Death Hospital, Institute nor _ j Cit Town or Village IDS�Q 115 Street Address (o�e,Y1.S F-(�1 JS Hosict( a Manner of Death©Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending 1 r Lu Circumstances Investigation tu Medical Certifier �N� s �i Title Q it RD autiv&Abui eath Certificate Filed Address J�—(�i', District Number Register Numb r) Cit , Town or Village C lens cal k 5 kO r 7 Date emete pr Cremat y 10-- 1�- 14 i ne �e, Burial ^e. a1-o ['Entombment Ad ess ,'Cremation acc.n burtA Date J ) Place Removed Z ❑Removal and/or Held 9and/or Address I= Hold 0 Date Point of ❑Transportation Shipment 0 by Common Destination Carrier ❑Disinterment Date Cemetery Address ❑Reinterment Date Cemetery Address Permit Issued to Registration Number i Name of Funeral Home M i ) er iy -pt,1 -kjryi,Q 0119.3 Address 6)C11S Indian Lk 12842 Name of Funeral Firm Making Disposition or to Whom 1- Remains are Shipped, If Other than Above Address is iu ` Permission is hereby granted to dispose of the human rem ins described abo e as indicat d. Date Issued P ) Registrar of Vital Statistics .? G% -t2-i- _ 2 / (sign ture) District Number Place k� i I certify that the remains of the decedent identified above were disposed of in accordance with this p mit on: ,`r� W. Date of Disposition 10(zoliti Place of Disposition etj, Vµ-a �i- q1or�, (address) LU {0 CC (section) j (lot number (grave number) a Name of Sexton or Person in Ch rge of Premises •, 11.4- Adi lease print) la Signature Title (17/t*0711, (over) DOH-1555 (02/2004)