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Waite, Mary NEW YORK STATE DEPARTMENT OF HEALTH` -itI n ` Vital Records Section Burial - Transit Permit Name First Middle Last Sex Y l�r L L . ��:4� f Date of Death Age If Veteran of U.S. Armed Forces, S/i If a 4 r3 V o War or Dates .1- Plar.P of Death Hospital, Institution or Vity bwn or Village �/�„y w tlt---- Street Address Ze'i II • Manner of Death©Natural Cause El Accident El Homicide ❑Suicide Undetermined Pending tLitil Circumstances Investigation w Medical Certifier Name Title Addre_§,s / r;lc-5 170 1-'-ere- Le-,, -r I I5 p,i I 3e,1 Certificate Filed District Number Register Number City, wn or Village ( Lett s -K U( s a 60 i a l3 0-Burial Date ` Cemetery or Crematory ❑Entombment s ) ( a `�( 3f,'-le. II vt c 7 Crc....4-. / Address ;;;; Cremation (>C�.1/4_ee-xs bs-t_r A.,)�,_-, .v( Date '0 ) Place Removed Z❑Removal and/or Held iii and/or Address 1:: Hold IA O Date Point of il,L E]Transportation Shipment ci by Common Destination iu Carrier Disinterment Date Cemetery Address Q Reinterment Date Cemetery Address Niiiii Permit Issued to — _ Registration Number ni Name of Funeral Home �_,�5i,,�.)rc _ A et, ( H. �2 vo-t-i v Address �^ Name of Funeral Firm Making l isposition or to Whom • Remains are Shipped, If Other than Above 2 Address CC U • Permission is hereby granted to dispose of the human remains described above as indicated. T Date Issued ci)(& /A 3 Registrar of Vital Statistics J C Q (signai1 tbie) District Number 5- t Place 6 tS f \< 5 j I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: k. 111 Date of Disposition 5 016 Place of Disposition �.� a,,, an a (address) LU fa CC (section) 4 (lot number) (grave number) iCI Name of Sexton or Pe on in Charge f Premises (pl ase print) Ui nature Title SiCP- IA't�c01( 9 T (over) DOH-1555 (02/2004)