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Peterkin, Daisy , #chi NEW YORK STATE DEPARTMENT OF HEALTH • 't Vital Records Section Burial - Transit Permit Name First r, Middle Last Sex Date of Death Age If Veteran of U.S. Armed Forces, IN 3 — 2 /7 2 v 13 87 War or Dates ,U/4 }• Place of Death ( Hospital, Institution or Ci own Village � 4-tCf-1`�r-A-- Street Address f/ 7ras A LVt - al 3 Manner of Death '0 Natural Cause ElAccident ElHomicide EllSuicide ❑Undetermined El Pending ui Circumstances Investigation 01 igi Medical Certifier Name Title Pct.0 ( Ge b 1,a r-c) uGc4e Address One Wes-i- 40e- 44 3_50 , 'c449c. 5P. it)) /ze6G Death Certificate Filed District Number Register Number niii City, Town or Village Lfr.5 (05 '7 El Burial Date Q © Cemetery or Cremory ❑Entombment U U �� r3p) Yle.. IA €'(0 6 /'eyvict� Address (��( `' C / G�� remation 2 b-kef- RJ , Quee v1S "up/46/ Date Place Removed o ❑Removal and/or Held and/or Address 12 Hold in 0 Date Point of Transportation Shipment iEs by Common Destination Carrier El Disinterment Date Cemetery Address • ❑Reinterment Date Cemetery Address PermitameIssued to >�t wm@ r� (ace Registration 6.5(Number iiSi Name of Funeral Home ��r-""5 i v r� j (��C�/,ll Address t/02 Mi,t,p/e 4ve ! Sae-w-f-e 94 5,0. 00., /2866- < Name of Funeral Firm Making Disposition or`to Whom Remains are Shipped, If Other than Above Address 2 1 ii ` Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued p$'a g 0 i 3 Registrar of Vital Statistics (,(ik (y`, C' (signature) District Number i+5 ld 5 Place mod,„ a , ic, t . •gi 111 at'1 f ammiiiii;_.>.::: I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Q /? I/ a ,l Date of Disposition O"a.9-,3 Place of Disposition i N� (address) in til iX (section) /� (lot umber (grave number) Name of Sexton Per on - rge of Premises 5etir.�r„/�f'A1 2 (please print) la Signature /Ai.d Title c "14 1Y-S I. (over) DOH-1555 (02/2004)