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Hall, Frieda NEW YORK STATE DEPARTMENT OF HEALTH ` ,, 'o[� Vital Records section Burial - Transit Permit A ',.: Name First Middle Last Sex ` Fr;elka I=_ -tof11 F Date of Death Age 1 If Veteran of U.S.Armed Forces, Oy O�{ /ap I�{ 1 D O War or Dates N)A Hospital, institution or City, l,►. Village ©vk.een,Sbl,-V Sheet Address 5 n A-O n Manner of Death DkNatural Cause 0 Accident 0 Homicide 0 Suicide El undetermined 0 Pending Circumstances Investigation Medical Certifier Name n D ©e p 1 04- Title Address " 152- SherrnAn 4ven,4e (Lprc fiat's A) / )Z >bI :s Death Certificate Filed Djstrtc� r> er Mister Number ' City, Town or Village ©+A e bk JJ Date 1 Cemetery or Crematory >i: ❑Burial ©L\ 101 10►4 Paie V,eco CA A ::::: cremation Address ,o, a ,n stivr y I izeoli Date Place Remove `�d Q Removal and/or Held != and/or Address a Hold Date - T Quint of i Ei Transportation _ I Shipment 3 by Common Destination Carrier Q Disinterment Date Cemetery Address []Renterment Date Cemetery Address . PermitIssued to Registration Number N NameameHa ynard vRer Fu,nera.f of Funeral Home Home.! O/13(:) ` Address ,/ La"T'o..t f? e (3t. , bl tef/Sb(,(-rj , /) 'lock- 1 o7'O1 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address : Permission is hereby granted to dispose of the human remains describli above as indicated. Date Issued l ? ic--)0I Registrar of Vital Statistics C- ____ G . sig re) <''- District Number' C9-"7 Place )0 t.9-,-- LL..r�S2-7-,-- �t - I certify that the remains of the decedent identified above were disposed of in accor " this permit on: f n Date of Disposition iit)1K Place of Disposition t'InrU,t�r ' anv.. (address) LE (section) lot number) Si (grave number) LoName of Sexton or Person in Charge of P emises 41 �wli� (please print) I. Signature iffiL.,. Title Ca/El (over) DOH-1555 (9/98)