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Wilder, vivian NEW YORK STATE DEPARTMENT OF HEALTH' �LI© Vital Records Section Burial - Transit Permit Name First Middle WLast/_k Q Se ir ��i Date of Death i/ l V ` ay\ Age n If Veteran of U.S. Armed Forces, 1 / U 2 Z - 1 3 / War or Dates 14 Place of Death Hospital, Institution or , r Z. City, Town or Village J Oh KS k ,A, b(.Street Address J �e n't-C r- Manner of DeathOja Cause El Accident EI Homicide 0 Suicide riUndetermined ❑Pending Circumstances Investigation ill Medical Certifier Name Title JeFF 4 ;��v1 hoc / Address NCO 60 � Nici r( I1v� / L2 UlGvefsvl trip /or )2()76 Death Certificate Filed District Number Register Number City, Town or Village /7s3 ` <:❑Burial Date Cemetery or Crematory Entombment �� Z _ P 1 4t�' V i e(J (Pe1 J. _Qy f '<> Address a '�7 ` < Cremation 2/ ulk R • n C..E P4 S• bur y �� Date Place Removed Removal and/or Held and/or Address itt to Date Point of ❑Transportation Shipment in by Common Destination Carrier Q Disinterment Date Cemetery Address Q Reinterment Date Cemetery Address ia Permit Issued to /�-_ Registration Number Name of Funeral Home (�' pc 55 �r,i1a. P - ( % ° U0 36L, Address q0 Z f 1/l.( (eif 1 v•Q_ SG vc1-7 1p• u k /286C im Name of Funeral Firm Making Disposition or to Whom 14 Remains are Shipped, If Other than Above Address lE 11,1 Permission is hereby granted to dispose of the human remainsdlappribed abolits ir�eliested. '< Date Issued/O ad /3 Registrar of Vital Statistics (signature) District Number 12�y' Place ��� ::::.`� I certify that the remains of the decedent identified a e disposed of in accordance w his permit on: jj ►► Lf Date of Disposition 10/79/3 Place of Disposition &Vuv `t-clofiw_. (address) ig IC (section) (lota number) (grave number) Name of Sexton or Person -n Charge of remises rs I L- .PNHIIf Z (plea print) >< Signature Title CaEMP-T (over) DOH-1555 (02/2004)