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Liebl, Joseph I .#3 ) c NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First � -.\o Middle �+ �� Last Sex �F�S-eph U. Date of Death Age If Veteran of U.S. Armed Forces, (-1 ?-20(3 5,5- _ War or Dates NO ace of Death ff ; Hospital, I nstitutio .r Ci Town or Village �tC.ns f cis Street Address �.! a is . '1�t Manner of Death Natural Cause ©Accident Homicide ❑Suicide riUndetermined ❑Pending Circumstances Investigation Medical Certifier ame Title Addre ��2 �x--.�. fit- �-�1�.�5_�I�.s l� �/Death Certificate Filed/� ,-- 1 District Number Regis r Number C�} r• Town or Village ICI S -1-0, 1 IS $ V� 'o 1 � I Date C eteryor Cremat ❑Burial I eC. l s i goj ,._ r) . V i u-t-crytalo rj Addre : Cremation i la► MS n, N Date ace Removed f Removal ` F and/or Held "-"land/or Address 5 Hold 4 I Date ' Point of 0 Transportation Shipment D by Common Destination Carrier Disinterment Date Cemetery Address _ Reinterment Date , Cemetery Address Permit Issued to r Re i ion Number Name of Funeral Home ± CV)E-r ' ilCa� I /cY) L /v c, I / y Address /i n ,.,_ol L 1 , ,,1 r A(�f 1 zstik, lit L_(,(_ 1' Name of Funeral Firm Making Disposition or to Whom "" Remains are Shipped, If Other than Above Address 11.1 14 Permission is hereby granted to dispose of the human remains descri ed' ab ve in ' t Date Issued Q�% Zv�3 Registrar of Vital Statistics i .E4.1 (signature) 2 Place C )16 t- 16 District Number c ' ) I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: 5 Date of Disposition f-11-1) Place of Disposition ge4t13 CNAirt` a (address) W N (section) /JQt.n ber) S (grave number) Name of Sexton or Person i Charge of Pr ises A 1 B``t�' (please print) W. SignatureCI z Title aCrt trai DOH-1555 (10/89) p. 1 of 2 VS-61