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Davis, Barbara NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section ` vim. Burial - Transit Permit • Name Fi t middle Last Sex Date of De th Age If Veteran of U.S. Armed Forces, 10 © /)e%9/X �� War or Dates 14 Place f Death Hospital, Institution or Z Ci , Tow or Village G ,�'. Street Address‘ 3..gj 7 7 ,(©T// a Manner of Death Natural Cause O Accident O Homicide El Suicide O Undetermined O Pending tilCircumstances Investigation 0 I<IJ Medical Certifier Name Titl / _ddreslig � h_c*." /A Death ertificate Filed District Numbe Register Number City(ow&or Village �j rt '- •OBurial Date ,�/ orr Crematory r� '° ❑Entombment 0// `„YA&// /il P !//-E'GC.2 f dia 4Y40,,/,,,,,,- Address MCremation 6-)Va e-gr -E .- �`ee,r cr ,V�t/A d` Date Place Removed Z Removal and/or Held ❑and/or I• Address In Hold 0 Date Point of ck"Ei Transportation M. Shipment 0 by Common Destination • Carrier O Disinterment Date Cemetery Address i!IEO Reinterment Date Cemetery Address Permit Issued to Registration Number m j Name of Funeral Ho cei''%Grp j/�, / 71/ (Pc2/<j/j nE Address iW/7 ei&c- .4/'7 / 5/ Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address cc t^ w 97 Permission is hereby granted to dispose of the human r ai s de cr'b bove indicated. iiiiiiii Date Issued iltg g/// Registrar of Vital Statistics f}L,(--tL (sig ature) District Number &5c Place \lt,o...71_, i . certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z 111 Date of Disposition Cy/-,3p-d Place of Disposition ,jvt /t,v0421000-k(...),/ (address) tt to (section) (lot number)) (grave number) ta Name of Sexton or rrs in a of Pre ises �e �1Gi�)numb Z (please print) III Signature e/W Title Celen'ib—ke— (over) DOH-1555 (02/2004)