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Barrows, Kevin NEW YORK STATE DEPARTMENT OF HEALTiW - 4 n 1133 Vital Records Section Burial - Transit Permit Name First Middle A_ast Sew/ eui ,u �, _ GAF-�- �os l Date of DeathAge If Veteran of U.S. Armed Forces, 0 ? — - Do J ef �S'r War or Dates Place of Death l Hospital, Institution or City, Town or Village CM w00 /0 Street Address � / r`O IL.) cl. (a c.K )-e d - j Manner of Death❑Natural Cause 0 Accident 0 Homicide p Suicide ElUndetermined El Pending t Circumstances Investigation mi Medical Certifier` N ��e�u C p Ti)40 Address Pa goc ld8- L,A r/qc,a i 102 qy, >' Death Certificate Filed ! District Number — Register Number City, Town or Village �Gf11�0 i0 ,/5 c 3 !f Burial Date n_ 11 Q /Y Ce tery or Ciemato ❑Er►tombn e I/ • ve U le C1^ei»'J A V'y Address G (Vf Cremation e,Am hi)k •y' Aix, Date Place Removed / Z Removal and/or Held 0❑and/or Address i= Hold Ca 0 Date Point of Q Transportation Shipment a by Common Destination Carrier 0 Disinterment Date Cemetery Address Q Reinterment Date Cemetery Address Permit Issued to l --. 1 Registratio//Numbern Name of Funeral Home L la 1—` e-r©i� FoN t -Ai )40704Q., 7 Address Or Y1Aio M-- 140&so10 Fiol/s r 1'. 1 21'37 Name of Funeral Firm Making Disposition or to Whom 1,, Remains are Shipped, If Other than Above Address I t } gli Permission is hereby ranted to dispose of the human remains described above as indicated. Date Issued 017 /‘ „VI i Registrar of Vital Statistics „, .i (signature) District Number C�(v Place _.„4 1-0 d ,) N/I certify that the remains of the decedent identified above were disposed of in accordancewith this permit on: Et Date of Disposition `1-I4-(9 Place of Disposition Zdyw (,k N— Z (address) ill re (section) / (lot numbq (grave number) Ci Name of Sexton or Person i Charge of Premises , ,,4 (-- Jx4a1i. Z (ease print) Signature *� Title COOK �) 9 1k (over) DOH-1555 (02/2004)