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Mckinstry, James NEW YORK STATE DEPARTMENT OF HEALTH 1 4 1 ` �j S}G Vital Burial Records Section - it Permit .t. Name First Middle Last Sex James- MQl v ,n 1-AcY)i nS 1 ' Date of Death Age If Veteran of U.S.Armed Forces, ;- . OZ12.3ja`O1`E ID? War or Dates iQi,AS-11toq ei -t P -ce of Death ( � �i Institution or w. City, own or Village C t-er,S 'EC s Street Address G 1 ens P-411 S foS,p, ►--ct I t, 'anner of Death ` Natural Cause 0 Accident El Homicide El Suicide nUndetermined El Pending $ Circumstances Investigation Medical Certifier Name Title v.t'; can,e 1 \1\) ov-i VA Address \U© \-A),r\4 S\-- . Glee =a\\S, /..)st 18OI Death Certificate Filed District Number Registe m r . - Town or Village k._ I e S- Fa\\� 6'f { / YJ Date Cemetery or ematory ❑Burial C)31 ,� 1 1* -P;r. \I eA. i Cnern a y Cremation Address .Qlr RO C a ,U i„ , o y i 2-809 Date Place Removed J Removal and/or Held tand/or Address s Hold Date point of cn Q Transportation Shipment a by Common Destination Carrier Q Disinterment Date Cemetery Address Q Reinterment Date Cemetery Address Permit Issued to �t `` Registration Number Name of Funeral Home'`- nar Funeral Q. faker nera-1 Home, QI) 60 Address / Lai' t l a gQ 1 a-�/:e#e �-• , be�.ee�s�x.e-n� ,dew /v k- y u. Name of Funeral Firm Making Disposition or to Whom 1,"' Remains are Shipped, If Other than Above •' : Address :,5, 3z w` Permission is hereby granted to dispose of the human remains d ab a icated. y Date Issued a` 2S 2lY Y Registrar of Vital Statistics - /e ��t (signature) . , District Number S60/ Place 642 C /`a /si Ayl 42 eIVY I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: L Date of Disposition 3 tab f f Y Place of Disposition � rw /�-ripr� a. (address) w CC (section) (lot number (grave number) 0 Name of Sexton or Person in Charge of Premisesd-OreL.- Z (please print) Signature 4,..._ ,..t...- Title Ci Mttpry (over) DOH-1555 (9/98)