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Cassidy, Frances NEW YORK STATE DEPARTMENT OF HEALTH �` `�"' Vital Records Section Burial - Transit Permit Name First Middle Last Sex C/ZAJcc 4Ar1ZATLA Q'Q s/©g ate Date of Death Age If Veteran of U.S. Armed orcces, A) .2y, 01O/c/ �f, War or Dates ,t,/JA 1.- Place of Death Hospital, Institution or -City, Town ur ge TiJP -k, Street Address kg -!t'�U/&Li (1,ei i^Pit..., ciManner of Death Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending Circumstances Investigation W Medical Certifier Name Title O At' /I YT&n!A /4J 1�S Address Death Certificate Filed District Number /��'1 Register Number S owtn-vr Village %jJ/ %AL,LL / (� ❑Burial Date ^� Cemetery oar crematory ❑Entombment ` / �� /d/NCB !✓/e241 C/� ic✓v/ Address Cremation 2/ f2CJAIG - ,.l nJ/a,,'i Al y / -go 1 Date Place Removed Z El❑Removal and/or Held 9. and/or Address • .t: Hold th 0 Date Point of 5 0 Transportation Shipment 0 by Common Destination Carrier ❑Disinterment Date Cemetery Address ❑Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home/S,'t,AJZi / //J( , c/o 9 S- Address 3t0 jme �'v4 — L4 ' Ml 4 All !� �- Name of Funeral Firm Making Dis osition or to Whom • Remains are Shipped, If Other than Above • Address > Lu Permission is hereby granted to dispose of the human remai - escribed above,as'ndi ated. Date Issued ,+ ^0?7—/LI Registrar of Vital Statistics / signatur District NumberA 7 Place 7r,c4),U cc- TUPP tAk, I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: P III Dispositiong U t fot t�• Date of Disposition ���'► Place of ,,� �! nwc� 2 (address) t 11 (section) (lot number) (grave number) 0 ' � • Name of Sexton or Person Charge of P emises A'ti il y 3 ttoAa- Z Tease print) • Signature Title CP4wiltt?'r42 (over) DOH-1555 (02/2004)