Long, Donald NEW YORK STATE DEPARTMENT OF HEALTH ��
Vital Records Section Burial - Transit Permit
Name Fir t Middlet 1 Sex
odd I I C t,/1�}rtia LG,�./Ct f�eZ L-
Date of Death/ Age If Veteran of U.S. Armed For es,
4 6 /3 ,g Z War or Dates ,-f I
}- Place of Bath Hospital, Institution or
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City, own r Village U ,J� Street Address i/2_ i c� <6,0 4.)--
a Manner of Death atural Cause 0 Acc ent 0 Homicide ❑Suicide riUndetermined ri Pending
_ Circumstances Investigation
w Medical Certifier Name Title
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Address
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Death icate Filed ( District Number ? Reg(ster uynber
City,(Colt
Village 0 - Af Q - ' i• (a
❑Burial Date Cemetery o Cremator
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['Entombment - ` - ---./3 --Address
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., 'Cremation Uli-Kb� Iy tl � (� U
Date Place Removed L /
Q❑Removal and/or Held
H and/or Address
N Hold
0 Date -Point of
N L. Transportation Shipment
0 by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to I Registration Number
Name of Funeral Home l'Aayoa C`i �. 6akt:, F Ltilet €: I H00
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Address
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11 Lc�-�Cc v/C_� }C_ , i r t( A ) Qv ( )Sbc-c I y , k ,..,..' `Jccr �< l ,k, Oi I
Name of Funeral Firm Making Disposition or to Whom
I-. Remains are Shipped, If Other than Above
2 Address -
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n' Permission is hereby granted to dispose of the human rem i s described above as ndicated.
Date Issued , - „o t3 Registrar of Vital Statistics
(signs ure
District Number 50 r.-) Place 04
Ccy______
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition q- 10-15 Place of Disposition <12(jtq... 6PCI Yft:10";if,—
(address)
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In
CX (section) ._ (lot number) 1 (grave number)
1D Name of Sexton or Person in Charge of Premises -_. ibkli4L 13,161__—___
Z I (p/ease print)
W Signature L 40= - Title ------- (l Jh1.3iNa.
(over)
DOH-1555 (02/2004)