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Braley, Rose NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit p. Name First Middle Last Se pS L Pt-1 r1 tr mkA t-t%y Date at De th Age If Veteran of U.S. Armed Forces, a /s 1 a O\L-. to-‘ War or Dates Place of Death Hospital, Institution or t_ Z - �PL`S City, Town or Village CO Street Address C�LC N 5 F A�t_s u©s i TA 0 Manner of Death Natural Cause ❑Accident El Homicide El Suicide ❑Undetermined El Pending 1tE Circumstances Investigation at Medical Certifier Name Title O S a�:A t•-s Iv RN-1E s x- C7 Address 10o Q Ne-g- SC (,t.Et�S FPLLs rti kago 1 ig Death Certificate Filed s F A t LS District Number O 1 Register Number :! City, Town or Village Vk-L t`' �' ..5 .S�{ ❑Burial Date is J 1 /I y Cemetery or Crematory P t - C \J,E t..I C'ttG cn AT C SL"\ Entombment Address i� ®Cremation QU A K-�i= `ko A Q,s L�.�s 4, •• 'i •.a , N-N`A t d10 1 Date Place Removed ❑and/or Address Removal and/or Held �, ; t) Hold Date Point of i1 Transportation Shipment t 0 by Common Destination Carrier Q Disinterment Date Cemetery Address Q Reinterment Date Cemetery Address Permit Issued to 1 r Registration Number Ep Name of Funeral Home ^\C1Ii,:',r \J .;CAME I Y a, s:A fat?‘"A O‘\3C) >: i Address . 11 Le. �` Sk C1vtR,,,s\v,E N-v 1 asoLA Name of Funeral Firm`Making Disposition or to Who • Remains are Shipped, If Other than Above a Address CC UI !"` Permission is hereby granted to dispose of the human.remains described above as indicated. Date Issued i al 'j ) J Registrar of Vital Statistics lJ%c�. �^ � �-c (signatu ) District Number 5 j bo 1 Place G 5• c� S / o V I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: 2 iti Date of Disposition i z-9-I y Place of Disposition ;„,,U.� e �e;V.S, (address) tii E (section) // (lot number) (grave number) • Name of Sexton or Person in Charge of Premises Gr+, �� 611.1 f (plese print) in Signature t' '�-- 4 Title f� CUPI .- (over) DOH-1555 (02/2004)