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McCarey, Eugene NEW YORK STATE DEPARTMENT OF HEALTH' ! It 76 Vital Records Section Burial - Transit Permit Name First &i. Middle Last ^ Sex die Date of Death Age If Veteran of U.S. Armed Forces, I I — /3 / / 0 War or Dates h o Place of Death ��p Hospital, Institution or n ifi_c_i_ r Village in Ct,d-�� . Street Address /7c , tcl-iu "7'� , rtIZ Manner of Death ykNatural Cause ❑Accident ❑Homicide ❑Suicide r-i❑Undetermined El Pending illCircumstances Investigation tti Medical Certifier Name ' Title fin '© i-. NiD Address �Yn Om .3 C0.4,.,__Lh St u'.6 a o o1 ScrAv +ir.z.1 -5, \'-( 1 - 4 frDeath Certificate Filed District Number �Ree N bet t , Town r Village �j 07 >>>` ❑Burial Date . Cemskte, or Crematory ❑Entombment " " ' / 4J ZO I L/ Y i kL V lam) Or� Address [ Cremation ] 1kSt,:1,1ti.0 t' k ,V , . Date Plac Removed Z❑Removal and/or Held 1.4 and/or Address 1z7 Hold U, 0 Date Point of �" Trans ❑Transportation Shipment L3 by Common Destination Carrier Mi El Disinterment Date Cemetery Address El Reinterment Date Cemetery Address iiiiii Permit Issued to LL _ Registration Number a Name of Funeral Home (_. Y�,pcc..SS't OYva t �14.-h.¢,tc ��AS... 00 3 4/Address /u1 `f o 2- -- 0. laDu 14--W►.2. 2.21-o �� , 1( J%�C . %? (p L Name of Funeral Firm Malting Disposition or to Whom Remains are Shipped, If Other than Above Address tr tx Permission is hereby granted to dispose of the human remains described ,,above as indicted: I'' Date Issued I 1-14- 2 tARegistrar of Vital Statistics L�iLp E___, - (signature) District Number y...54o Place ac_5 0 „ 57 )--? c J / >I /a O Z 0 y I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z ill Date of Disposition 011l11 Place of Disposition g,IL.„ cr..„,,--- (address) fIl CC (section) f (lot number) (grave number) Name of Sexton or Person in Charge of Premises Af i ' ' Mt Z 'please print) Signature 14. G f�4j�- - Title r iZ1cw} " (over) DOH-1555 (02/2004) k