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Holland, Elanor NEW YORK STATE DEPARTMENT OF*1EALT,,H Vital Records Section Burial - Transit Permit Name First Middle Last Sex Z--; Lak",t)r c, Pr, 1 IAAA -1-- Date of Death Age If Veteran of U.S. Armed Forces, I / fSh 4/3 '3 5 War or Dates f- P _ -- of Death Hospital, Institution or ZatIO own or Village r,-1- r.., Street Address 3 S Ne_..� S}r'4L-& 0 v anner of Death©Natural Cgus cident Homicide Suicide 0 Undetermined Pending I t Circumstances Investigation W Medical Certifier N e Title 0 �G; GA 04 - 6r a ss MD A dress /,), .. reLr`( sJ-. 62e,, 771 of )).> /aAa( Death Certificate Filed District Number Register Number .,CCit Town or Village SARATOGA SPRINGS �,5.0/ ❑Burial Date / Cemetery or Crematory f ❑Er.#crz5mer.# I1 l 1 / aol ,,44_V: w C.�l'-c..K,, .r Address ni[ Cremation �G, s.SJ Ales-,, 'IL.r Date Place Removed Z❑Removal and/or Held 2 and/or Address F Hold (I) 0 Date Point of i Transportation Shipment 0 by Common Destination Carrier _ Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Ho C/iS more ,�.�c.__ Qb `f`�'- �f Address 7 5 e_!'.h,a., -I �e. 0"l Ne % g�- Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above 2 Address C I ` Permission is hereby granted to dispose of the human remain rib ab a - dicated IV Date Issued ►1 � 61 /13 Registrar of Vital Statistics (signature) District Number Place SAkATCGA SPRINGS ; I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: ILI Date of Disposition /1/, /3 Place of Disposition g,v/f. p-- W (address) CO #C (section) t nu ber) (grave number) Name of Sexton er n . Charge of Premises J " ��` ''� Z � /� (please print) 14 Signatur � c%-- Title C r .074-YOK- 45 (over) DOH-1555 (02/2004)