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Beman, Timothy NEW YORK STATE DEPARTMENT OF HEALTH f I u'E' Vital Records Section f 1I Burial - Transit Permit Last ;r Name First / 7./ � ��- A ,L7/9, F.: Date of Death Age If Veteran of U.S.Armed Forces, =` --7_S/ad/ 3 cS war or Dates Place of Death ! _ " City,Town or Village d r S J�-f3 4 S StreetSP Add Institution E4.S f}L�.S / ,5PI/69 L 7 Manner et Death M Nafival Cause El Accident El Homicide ❑Suicide ❑Undetermined . ❑Pending Circumstances Investigation H. Medical Certifier Name Title 2A"/e Address C.,e, co es D C,4#.tC- c__, 2-.E.e off. PAie,t. s< ti_..c. s /: f} Death Certificate Filed ,.,j / District Number ITegister um if Cr,Town or Village l A- .LS s ` � �,4 yCrediatory<;L7i3uriai D 7/oea--;V 6 3 C�� U G'� i4 icy e��/`/ Uedombment Address �. ..laCremation / J41E€ C,„, ,, c,,,e AJ ,Q# -: ' Date Removed / k ` Removal [� and/or Held and/or Address Hold Date Point of Transportation Shipment by Common Destination Carrier 0 Disinterment Date ` Cemetery Address 2y' k:¢: Q Renterment Date CemeteryAddress Permit Issued to J. Registration Number Name of Funeral Home ,,©<V ct— /� C / S-' Address l2 /9-ERA/ 6,4 .s -ems A/y / _'e l fa Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address Permission is h granted to dispose of the human remains described above as in A Date Issued ' 3 Registrar of Vital Statistics /``;��' 6z,- Ez<: (signature) District Number L5 / Place 6/6.%7./ /4 /( /9W I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition 7-'713 Place of Disposition Piot us,v, 6ti-t o,r,`, W ( ) ,r, (lot numberye4 (grave number) 40 `�, Name of Sexton or P in Charge emises q *lease Pil <: Signature . _ Title CatrateC (over) • DOH-1555(02/2004)