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O'Connor, Robert f a.x i/ 77.3 NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Ei Name First Middle Last Sex IC610 \A' E6,1 0 Cofroi o , fl'i Date of Death Age If Veteran of U.S. Armed Forces, VAS p 0 / i 6 I a O 13 77 War or Dates J'7^61 Place of Death I f ---� Hospital, Institution or ,4c1 ,,. �. k At v- City, Town or Village `., L(d inns bu Street Addressiii fiu vs. , ys ,e(„ � f f t Manner of Death rj Natural Cause ❑Accident ❑Homicide ❑Suicide ❑undetermined ❑Pending Ill Circumstances Investigation tu Medical Certifier Name Title /) O hl 6,3 4 ( G w,h 2 /�,/�i Address ( � ��� �� S3 / i r2 SIB- ZO C).) 11�Q Cam,,, „iv Death Certificate Filed .�( / District Number Register Number City, Town or Village in o$ Jo he)C40 c��, S S /O El Burial Date I Cem or Crematory C�I16I a oi3 f",-vsL V% et,3 ( re4 ? a_-i'ovv ! ['Entombment Address /i t� 1 '' Cremation �v0: MS Lo Al / ,a 3 7 6 Date Place Removed ❑Removal and/or Held and/or Address t" Hold 11) Date Point of Transportation Shipment L by Common Destination Carrier ❑Disinterment Date Cemetery Address ❑Reinterment Date Cemetery Address gi! Permit Issued to Registration,Number Name of Funeral Home P&L/ h o—ci 0 6, lot., YU c-U61,1. © // a Address Qt ti .12_,-tf- QS+. sq,,JPC_In.S k) \i/ if;-8-6(/ Name of Funeral Firm Makin Disposition or to Whom '( ▪ Remains are Shipped, If Other than Above ', Address CZ Ili Permission is hereby granted to dispose of the human remai s described a e as indicated. Aii Date Issued GPO/ �1J/ 3 Registrar of Vital Statistics . E (signature) District Number S Place ec .1:I cI certify that the remains of the decedent identifie above were disposed of in accordance with this permit on: k /' lU Date of Disposition s-13 (3 Place of Disposition -e�,Ocw l r+�'rrcjic a (address) to le (section) number) (grave number) 0 faSehr(V, Name of Sexton or Pers n in Charge of Premises /1f ) cflLt, ► (please hint) • Signature L Title 04111604 (over) DOH-1555 (02/2004)