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Rogers, Elinore NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First'EL.ii,Jora ---N Ar-E. lc 06-altr F. --f--- Middle N Last Sex Date of Death Age If Veteran of U.S. Armed Forces, ��� :—] -� 3 War or Dates -• P e of Death Hospital, Institution or— Town or Village �j f Street Address I HE- r1 tvt--r(J (F anner of Death©Natural Cause El Accident Ei Homicide El Suicide ❑Undetermined Pending tij Circumstances Investigation W Medical Certifier Name Title DERPPr)tb z Vit-LiC5LA &lb Address 110 t Z- -,' 1 S i cW l 4 7 Death Certificate Filed District Number Register Number City, Town or Village O J(o Burial Date II r `3 C tery or�Gremato � ❑Entombment 1v i ` Address � g ❑Cremation C '' /" Date Place Removed Z Removal and/or Held 9 I—land/or Address Hold fill 0 Date Point of 05❑Transportation Shipment 0 by Common Destination Carrier 0 Disinterment Date . Cemetery Address Reinterment Date Cemetery Address fii Permit Issued to i.6 Registration Number Name of Funeral Home h14 Ill. L.4 FH 0 io`7J Address '', )3to rit47A) : SioF 1 Name of Funeral Firm Making Disposition or to Whom • Remains are Shipped, If Other than Above 2 Address l Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued I / I? //3 Registrar of Vital Statistics l/ .) (signature) District Number 560 I Place 6 S co, t is) iy certify that the remains of the decedent identified above were disposed of,in accordance with this permit on: III Date of Disposition Place of Disposition 2 (address) 111 VI CC (section) (lot number) (grave number) Name of Sexton or Person in Charge of Premises z (please print) I Signature Title (over) DOH-1555 (02/2004)