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Thompson, Barbara NEW YORK STATE DEPARTMENT OF HEALTH- *. Vital Records Section Burial - Transit Permit Name First Middle Last Sex F parbcLrc-- - --"cOCc,r1 1 hor or Date of Death 31 15 iao t Age . If Veteran of U.S. Armed Forces, War or Dates 1 Place of Death 6 - ylde To w erift#ager c L. h 5 bur treet Addre /© ' A Ip i - `,Q ue ` aManner of Deaths Natural Cause 0 Accident 0 Homicide 0 Suicide Undetermined O Pending W "' Circumstances Investigation tu Medical Certifier Name Title poc Address I t LGJf (� (d i JOUICtickuy 1P i Death Certificate Filed Distr t Number R ester Number City, Town or Village ['Burial Date 31140IS remator : i ['Entombment Address /�'� remation l.�(U-OI-�k,r` 2 d ., Q` - -►m bury 1 (Q l5 04 Date Place Removed g 0 Removal _and/or Held and/or Address I Hold Date Point of • 5 0 Transportation Shipment a by Common Destination Carrier El Disinterment Date Cemetery Address iii'iEl Reinterment Date Cemetery Address Permit Issued to 1 Registration Number Name of Funeral Home �t a/)Ltrd b, r F/ 1. Oh 1 3c Address 110 Name of Funeral Firm Making Disposition or to Whom 1„-. Remains are Shipped, If Other than Above Address iii Permission is hereby granted to dispose of the human r . s described ab e s indicated. > Date Issuetg aot Registrar of Vital Statistics _Q. n.A.t--� ------ (signature) District Numbeaacn Place l d -- d -( Q � 1 I certify that the remains of the decedent identified above were disposed of in accordan a wit this permit on: I Date of Disposition 3 —13 Place of Disposition pj,tjL N' (mac/ 44-avel v 2 (address) COIll CC (section) � ‘/ (lot number) (grave number) ta Name of Sexton Per on in ge of Premises � l�*" /KO-'/ . 2 (please print) Signature / `'i Title l hli/4re._ /4J% (over) DOH-1555 (02/2004)