Vincent, Donald - S7O
NEW YORK STATE DEPARTMENT OF HEALTH ), _
Vital Records Section Burial - Transit Permit
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1,',e40 • ,
Name First Middle
;•.?:.,: .. _._ 1Vc II Last
sCt .6___
Sex
4 . : 1 le.,
Date of Death 1 Age , If Veteran of U.S. Armed Forces,
A,
<3 ( 11 aoi3 (a-is War or Dates ....--.
',:: P e of Death Hospital, or z i
Ci own o Institutionr Village 6Z,445 -- 11-1---- Street Address Co Le4s __F‘.115_ e .
anner of Death raj Natural Cause 0 Accident 0 Homicide 0 Suicide 7 Undetermined Pending
". 'Circumstances Investigation
Medical Certifier Name , Title
JP 14. --,.x. L---. .. - s lver fri
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Address
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bi Death Certificate Filed \ istrict Number Register Number
or Village () Lc-t,s •+-" %- II S'"-- -6
Date Cemetery or Cremator
Burial A-A 17 'A 013
i
Address v .
Cremation a,.....k.,ce--- ....,( ,....‘ A)c....,....., 7-31<
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Date j ' Place Removed
Li
=Removal
0 and/or Held
and/or Address
Hold
0 Date Point of
(5.• El Transportation . Shipment
a- by Common Destination
Carrier
Date Cemetery Address
0 Disinterment
Date Cemetery Address
Reinterment
Permit Issued to Registration Number
Name of Funeral Home c---Arivta rc ,F. A tr4 )--11,,,e J. 00 i1-4r6
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Mi Address
—7 si,er, , Ave r. -4— i Q Y.
i,..C.; Name of Funeral Firm Making Disposition or to Whom/
Remains are Shipped, If Other than Above
Address
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4
in Permission is hereby granted to dispose of the human remains described above s In at d.
Date Issued Z /a-7 /13 Registrar of Vital Statistics
(signature)
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b District Number •)-- °/ Place (.;;LA.s --I:LES- , Pc.---) / /s,"(.
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I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
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E Date of Disposition Rio /5 Place of Disposition elv-,C._ V, t4,./ C&A.1,40,4y
(address)
0
cc (section) 4 (lot/07) (grave number)
° Name of Sexton o ." - s,‘ in Charge of Premises $,4
n
(please print) e
4.4 Signature 0 , i#411/
at_ri
CI Title A 4v/L/ 4 43 _
,
(over)
DOH-1555 (9/98)