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Masner, Thomas -7't 3 .)c-- NEW YORK STATE DEPARTMENT OF HEALTH • , '-) Vital Records Section Burial - Transit Permit Name First Middle Last Sex Date of Death Ag I If Veteran of U.S. Armed Forces, „(� 'jo 14 5 War or Dates N( #- Place of Death Hospital, Institution or Zi ,•Town or Village r7 POLS Street Address 0 Manner of Death 41 Natural Cause Accident Homicide Suicide Undetermined Pending 't Circumstances Investigation ul Medical C�ifier Name Title C r �Y�� KA Address 5 _ Death Certificate Filed District Number Register N b r Cit , Town or Village ble,r,s 1- «S 540QI 0Burial Date � {{ etery�9r Crema ory �c ❑Entombment ���_2pl "[' 1 Y 1 ' Y2) AddrbsLLC �� Cremation Lv'�L.� Date J Place Removed Z❑Removal and/or Held 91. and/or Address tt Hold CA ei Date Point of fik El Transportation Shipment a by Common Destination Carrier Q Disinterment Date Cemetery Address Q Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral HomeZ )nc. ©©c,(1 Addresses l_YlU.th c Loo_ LuzDiu____ _LW 12,S1/40 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address 2 III P` Permission i hereby granted to dispose of the human remains described above as indicated. Date Issued(0 0(5( )4 Registrar of Vital Statistics 030,..1/4„ k..,,,,,„vat- (signature) District Number 51p DI Place ( 6da?sk(Ls .:...--,: I certify that the remains of the decedent identified above we disposed of in accordance with this permit on: iii Date of Disposition—v/9"Place of Disposition //tl‘ Y j, .u/' Cbaleil-4,15/ 2 (address) ill in IX (section) / number) (grave number) D Name of Sexton o � o i Charge of Premises :, V k®`')_ion L i �► (please print) W Signature Title 0I..);:print) l "� (over) DOH-1555 (02/2004)