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Collins, Walter NEW YORK STATE DEPARTMENT OF HEALTH , 1 it 399 Vital Records Section Burial - Transit Permit Name Firs AL7-E, 6 C©Middle Last Sex Date of Death Age If Veteran of U.S. Armed Forces, 7���l�/.� War or Dates Place of Death Hospital, Institution or � fi City, Town or Village 6/G S /-t.C.S Street Address /36 IV+.a9T7Z 6d( ic1S 1�t.Gs All Manner of Death Natural Cause 0 Accident 0 Homicide Suicide Undetermined Pending lid Circumstances Investigation iLi Medical Certifier Name Title n O 60911 All ifbiri,d) /0 Address di C e y Rel attdi.4s g i L/ Death Certificate Filed // ,i- District Number Register Number City, Town or Village (Y'� — S' /4"91 S Si,e / ,V ❑Burial Date Cemery or Crematory _ ;;;:;;;,Entombment /41. 0i0as �> aThsertaI Address �p� IIIIN Cremation c / >rrQ , 444 �7 /c v Date Place Removed Removal and/or Held and/or Address Iris Hold O Date Point of IliTransportation Shipment Gl by Common Destination Carrier _ Q Disinterment Date Cemetery Address El Reinterment Date Cemetery Address s Permit Issued to Registration Number Name of Funeral Home 4<t 4-7 t ,+tJ( /'V Address/3 6 A)Ra.eC/v 6-.46JS > tS al y /&fO Name of Funeral Firm Making Disposition or to Whom / Remains are Shipped, If Other than Above • Address tr LU LL Permission is hereby granted to dispose of the hum emai s dtribed above ,s ind- ated. Date Issued 0'0 ,yg... Registrar of Vital Statistics „ ° - ('gnature) i District Number / Place !a Ito t A-c___ _6.) >::<::: I certify that the remains of the decedent identified abov were disposed of in accordant ith this permit on: Z I Date of Disposition 7(`(it Place of Disposition '?�uuJ r .,�`ori� 2 (address) in VI is (section) (lot number (grave number) Name of Sexton or Pers n in Chargf Premises- . / 117+A r t��� Z / (please print) Signature <SID Title Ctil";Al}1a�- (over) DOH-1555 (02/2004)