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Bullard, Kevin NEW YORK STATE DEPARTMENT OF HEALTH 4 Z cf. Vital Records Section x' ' Burial - Transit Permit Name First Middle Last Sex I{e .\I I In C Z u l I a_rd Ma k- Dategf Death ,J Age , / If Veteran of U.S.Armed Forces, -.2.1--i `t" '-j ( War or Dates I\0 h` Place of Death Hospital, Institution W, City,Town or Village City of Albany or Street Address A(bar\y e d i C Q j , Manner of Death Natural V ❑ Undetermined ❑ Pending hill ❑ Cause Accident El Homicide El Suicide Circumstances Investigation Medical Certifier N me Title © j oar\ ke_e jt i' _ Address j 1 a. 5 .--i--C. St . .1\1 i Death Certificate Filed J District Number Register Number City,Town or Village City of Albany 101 Date .... ._.4metw or Crem tory -' ❑ Burial 09 d-5 1 0 I q 1 C� 0 Entombment /n� I Ct� Cremation Addr ss a1Eikr1 Z Date Place Removed Removal and/or Held 0 ❑ and/or Address l� Hold U) 0, Date Point of 0. Transportation Shipment U) 0 By Common a Carrier Destination ❑ Date Cemetery Address Disinterment El Reinterment Cemetery Address Reinterment C£ Permit Issued To Registration Number .1 Name of Funeral Home 1 c-c pea ' Inc O I I Address � , 4 -1L.t.rc S LLiJ6 t L.u.Ze.r 711 f tJ 6'��o /o Name of Funeral Firm Making Disposition or to Whom "` Remains are Shipped, If Other than Above " Address ir- -1t " Permission i is, hereby� granted to dispose of the human remains-described above as indicated. `7 Date -. ,tgo I LI ('-._._._______ Registrar of Vital Statistics ,,- ' Issued sign District Number 101 Place Albany F sign Department City of Albany, NY f4e4 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z Date of Disposition WINN Place of Disposition gigi.4 C' 'Orr•--- ILI (address) 1JJ' 0 (section) 4 (lot number) (grave number) 0 Z'' Name of Sexton or Person in Charge of Premises s �tndt1 W (please print) Signature4 Title ( ►14-0aZ, (over) DOH-1555(02/2004)