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Montgomery, John H if 73 NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name Fi '��� Nji�idle ,��,e/" 4st" I Sex �° ry _ is Date of Death Age If Veteran of U.S. Armedorces, t.e`7/a ""/ I 0 War or Dates 44 Place of Death I Hospital, Institution or © Cit<own o Village L 1 i'f L�ze T,�g Street Address I 7 S"`� T t (( Manne 0 eath `1 Natural Cause 0 Accident n Homicide Suicide Undetermined Pending AsjCircumstances Investigation <fT Medical Certifier Name _ Title Address -�,�t.. �+-\ ',�„er e ..-_...i ,/ i d a�-- Death Certificate Filed 1 District umber Register Number Citywn bt-Villagel i L�z-cf;-c_.._... j ' 3 Date Cemetery or Crematory [ • m Burial /)-1 �),0/`. ,,ts y,e..--- ''r,,..1 -fir D��11"" Address / Cremation �7�ct�s(J Ai_ Li: ;l �� c ��! Date Place Removed 2 In 0 Removal and/or Held �— and/or Address Hold O Date Point of v)Q Transportation Shipment a by Common Destination Carrier Disinterment Date Cemetery Address Reinterment , Date Cemetery Address Permit Issued to , Registration Number IIIIg Name of Funeral Home -Dens�� � (� `Yy��_ p -,` Address „.. -77 i AA A.m. A-Ve- .,,,,d;: . A) r � Name of Funeral Firm MakingDisposi ion or to Whom J ;; P Remains are Shipped, If Other than Above Address IItti + Permission is hereby granted to dispose of the human re ns describe above as indicated. ' Date Issued / -- -/4 Registrar of Vital Statistics All,C Q 1 ,�� > (signature) i �c'O IIE District Number 4Sco Place I-600 ft-�c Z..1 r-Y? e— I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: f- W Date of Disposition f/30lit( Place of Disposition :Ojai.) ( r J,.,. 2 (address) LGJ tR CC (section) DQ//� (lot number) C. (grave number) 0 Name of Sexton or Person in Charge of Premises /W.st is Sarrail (please print) W Signature dirk_ �,� Title aim Pat (over) DOH-1555 (9/98)