French, Genevie NEW YORK STATE DEPARTMENT OF HEALTH
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Vital Records Section Burial - Transit Permit
Name First M dle Last Sex
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Date of Death 1 Age If Veteran of U.S. Armed Forc ,
te 2 4 I i 3 ____-----_ -__ST 3 War or Dates {
i- Place --ath 1 Hospital,�lnstituticr r
WCit , Town` r Village !`T , a W eyt.� Street Address FO -' 174Aa do...,_)
O Man - of Death Natural Cause D Accident ElHomicide 0 Suicide riUndetermined ri Pending
_ILI _ _ Circumstances _Investigation
W Medical Certifier Name Title
CItI /ee() Spine
Address I cal r e,l 0 j , J Q, .ry ou : , J�7 as
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Death Cate Filed District Numb Register Number
City, Town Village j, g-A wfl, Z I
Date Cemeteryr Cremator a6,..,
❑Erato tt (_ ZZ /3 /A)e-
❑Entombmentl- —Address y
mation 09-jCL '-- l . C) V iQ_-
------- ------- --
Date Pldce Removed
Z El Removal and/or Held
and/or Address -- —
-
E — — — —
Hold
---- — —
d . Date Point of — —_
Q Transportation ( Shipment
O by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to -0,
_ I Registration Number
Name of Funeral Home M c nal c� 0, c ker rLLne r a.I "k`o rok- --- 1 1 j 0
Address
11 LatoyQHC. 1 . , wcn7 ktv , ►vC yui k_ \ Ld i' \
Name of Funeral Firm Making Disposition or to Whom
M- Remains are Shipped, If Other than Above
Address
tk
W — — - - - - -
fl` Permission is her by ranted to dispose of the human m ins descri e abo as indicated.
k
Date Issued C3 Registrar of Vital Statistic
�._ (signatur
District Numbed Place Ai- 7472-7_____&Zja _ —
I certify that the remains of the decedent identifie iove were disposed of in accordance with this permit on:
WDate of Disposition Place of Disposition
W (address)
Cl) _-- --
r (section) (lot number) (grave number)
Q Name of Sexton or Person in Charge of Premises _______-___
Z► (please print)
ill
Signature __ —______ Title --
(over)
DOH-1555 (02/2004)