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Brown, Stephen it S- NEW YORK STATE DEPARTMENT OF HEALtH / 2es Vital Records Section Burial - Transit Permit Name F. s L t Sem Tyin, Date of Death l Ag If Veteran of U.S. Armed Fo ce s, ''�v�`�/�i3 W or Dates li Place of Death nn' os it nstitution or D Q p AA aQ� /J�,r,, Cityla , Town or Villa e A,..d,maxi/ Street Address /©d/ r/IJ 21 G-�43 eY i Manner of Death Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending 1U Circumstances Investigation tu tu Medical Certifier Name f Title eA 10 Ad ess Death Certificate Filed District Number r, Register Number ini City, Town or Village NI 0 Burial Date 9/3/'i3 Cinlet?ry or Crematory r -,u2 ! s2_4_4, ['Entombment A ress �( 'Cremation C� ���-F�-�L A eQ. 6IN04 1d y Date Place Removed ❑Removal and/or Held and/or Address = Hold to 0 Date Point of Transportation Shipment G' by Common Destination Ei Carrier El Disinterment Date Cemetery Address iiii❑Reinterment Date Cemetery Address «<'.9 Permit Issued to ,/ Registration NNmber Name of Funeral Home `' • '). r1 a) 07 Address �� l a 3_ Name of Funeral Firm Making Dispositio r to Whom O Remains are Shipped, If Other than Above 2 Address tr L Permission is hereby grantedra to dispose of the human remains described above a/ indii ee.. Date Issued /1�.J Registrar of Vital Statistics %SY �C -9 (signature) District Number 560/ Place ( d s<_I cI certify that the remains of the decedent identified above were disposed of in accordance with this permit on: k Ili Date of Disposition 't(K lt3 Place of Disposition £i Iv Ci c1,0(),... (address) Ili til ICE .(section) (lot number) c (grave number) 0.1 Name of Sexton or Pers n in Charge of remises i, � 1" Z (p ase print) SignatureTI Title CIZOVAC (over) DOH-1555 (02/2004)