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Beaupre Jr, David 1/1 It NEW YORK STATE DEPARTMENT OF HEALTH �(+ Vital Records Section Burial - Transit Permit Name�F t SeAV 1 Middle �� iteLast T /` Date of Death A9 b If Veteran of'.S. Armed Forces, � „�nT 7 RON War or Dates ,A* . Place of Death Hospital, Institution or j City 4 own ir Village FT. OW,) Street Address /jrM�f/.d )'/lf/,ryfh'#" Ul , C_ Manner o death Natural Cause �Accident 0 Homicide 0 Suicide �Undetermined Pending tij Circumstances Investigation uj Medical Certifier Name Title Address � � /3i itt' -, r. ���, NY. /,fi ;i Death - ificate File 1 Iistrict Number Register Nuynbb `: City, own-e r Village,EJ�i.I .S7 (pp IN DBurial Date CPi etery o Crema ry r. a? 20/ y Verb / I97Ply ['Entombment i Addre 2.3Cremation cUEEJJShgrc / Jf-/ . Date Place Removed Z a Removal and/or Held and/or Address t Hold in 0 Date Point of e Transportation Shipment p - G by Common Destination E. Carrier Q Disinterment Date Cemetery Address ql!IllQ Reinterment Date Cemetery Address iiiiig Permit Issued to /� , �, Registration Number Name of Funeral Home Mvyuq/� D. &afit / iQt J /hol t 0 i i c) iiiii Address S. Name of Funeral Firm Making islosition or to Whom / AI }- Remains are Shipped, If Other than Above Address ft fit 0::` Permission is hereby granted to dispose of the human r ins described bove as indicated. Date Issued J , a 20/y Registrar of Vital Statistics d L Psignature) .--------^ Ect t-d iiiigi District Number 5 7� Place �� %}�.� :_ I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: 10 ILI Date of Disposition_ 4(3©t 4 Place of Disposition -ELL (�,.,t+. (address) ill VI J (section) /' pot numbr) (grave number) Name of Sexton or Person in Charge of Premises a "ti 1 P lease print) ig iiig Signature 6"��� Title Cif al'itirA (over) DOH-1555 (02/2004)