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Batease, Deborah 1 11 NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial _ Transit Permit NarRe First Middle Last §,ex Date of Death Age If Veteran of U.S. Armed Forces, 1 _ —�-LA 9 7 i War or Dates Place of Death Hospital, Institution k or :Z City. Town�or Village ( n c) i a i'\ LCj<.4 . Street Address(13 � /t 30 fl Manlier of Death D Natural Cause Q Accident 0 Homicide 0 Suicide Undetermined El Pending Circumstances Investigation iii Medical Certifier Name Title Ps^ I I I Cl- M� Address Lo r Lc kA.f. 1ti � .... Death Certificate iled District Num a Re ister Number City own, r Village 111 t(U\ Lit k:-.- ! •©-j 3 ? 7 Dateemeter r Cremat y ❑Burial i )a\O3 i tk. Addre Vj Cremation i lASLAZ Z ALL ____ _____9_____ Date J Place Removed 0a Removal and/or Held and/or Address N Hold 4 Date Point of N0 Transportation Shipment G by Common Destination Carrier Disinterment Date _ Cemetery Address Reinterment 1 Date . Cemetery Address Permit Issued to Registration Number Name of Funeral Home M t t €c -iIv.r-a` t,• WTI ( Address (8 35 S}ci - 30-_-_) na t art Latt._.N 11 D. Name of Funeral Firm Making Disposition or to Whom Remains are Shipped. If Other than Above Address — ak a Permission is hereby granted to dispose of the huma rem ins described bone as indicated. Date Issued l L\. 3t 4. Registrar of Vital Statistics 6 ice /2 ( f_ J f'�1 _ signature) District Number ),D E 3 Place I O+.i1 t\ Lf I n lkr\ 6 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: I- tiiDate of Disposition IL�2ji Place of Disposition i.Uf w 641441o,,u,—, 2 (address) 0 CC (section) (it number) (grave number) Name of Sexton or Person jn Charg of Premises 5fi �+w�f`� Z (please print) C9 W Signature t Title 174A4 DOH-1555 (10/89) p. 1 of 2 VS-61