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Edwards, Harold NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex ‘Aaro\6 �Z ,i Erdwar I Date of Death Ag� if Ve�of U.S.Armed Forces, 03) o to 1 apv War or Dates 1 Q`t o-i 9.-+-9 of Death Hospital,institution or �` , Ff-100 own or Village GI en rot\1S Street Address t�t ner of Death Natural Cause ❑Accident U Homicide ❑Suicide ❑Undetermined ❑Pending Circumstances Investigation f * rn• Medical Certifier Name Title C Y o \ ,11ai,�An P-I Address I C_o,re Road , auk.nSbur) , N , O y 0,,„u Death Certificate Filed -District Number Register Number Ev: C.-Y.Town or Village G 1 ens rc.1,,S , '1 /T r--t Date Cemetery or Crematory u-Burial C)3 ) 1 1 ) o"4 D,ne. V,eu3 Ct'emCl flf Cremation ( 0.� x"!►, tk[�QC� i ©�.QDyIS bu►. / A) •y. d Address Date Place Remov0-1 ed ❑Removal and/or Held and/or -- - •• Address r Hold •61 Date Point of `, 0 Transportation Shipment a" by Common Destination Carrier , ❑Disinterment Date Cemetery Address ❑Reinterment Date Cemetery Address Kg Permit Issued to / Registration Number Name of Funeral Home r(aqra rd v, ker Fw ecc i Home_ 01130 tl Address 11 LafoL j tc c5f. , beite.e�shi n J , A-JeL0 VOrk i 'oy ki Name of Funeral Firm Making Disposition or to.Whom s Remains are Shipped, If Other than Above i Address Permission is hereby granted to dispose of the human remains described above as indicated. gi Date Issued // 1 ) I`/ Registrar of Vital Statistics W fi '-A LA) (signature) Place 6 C',ti'.S `S A) v District Number 5 GO( o _ I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: ' Date of Disposition -/2/4/ Place of Disposition /Q'V4 v' -✓ 0--/ere-Prie44-7" (address) fA .y (section) (lot number) (grave number) •a• Name of Sexton or rs ge of Premises (please print) /� .' Signature c Title C%}C.�iN A4- jam' (over) DOH-1555 (9/98)