Beagle, Linda NEW YORK STATE DEPARTMENT OF HEALTH li -7 IT
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Vital Records Section w , • Burial - Transit Permit
tm Name First , Middle Last Sex
Name us f.ds w - 62p... .z. •
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Date of Death Age If Veteran of U.S. ArmerForcess ,
k IN la ti I 3-6t3 (0 -1 War or Dates _
Place of Death Hospital, Institution or
City, Town or Village MO me-%-)
, .1 Manner of Death
N Natural Cause El Accident 0SHtreoemticAiddedrea
Suicide aat Lari Undetermi? d ri Pending
'Circumstances 'investigation
'4) Medical Certifier Name .
Title inD
O 6: y 51- , ;
..... Address
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Death Certificate Filed District Numberq56, Register Number
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City, Town or Village z Lii't
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:•:•: Date Cetery or Crematory
ElBurial a lacy 1 R 2615 V,Ae.... \I 1 t...x....s cs-c_,,,...(-0.-3
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• remation Address
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Date Place Removed
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Li Removal and/or Held and/or
}!; Address
a Hold
O Date Point of
El Transportation Shipment
E by Common Destination
•:•:: Carrier
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-.•:. ,--- Date Cemetery Address
:: I___,: Disinterment
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Date Cemetery Address
:H LI: Reinterment
ag Permit Issued to Registration Number
q•4 Name of Funeral Home 'ge„,tv5vvv.c::. r-C_ C1/4-1,Ne.....-rJ \-lavv\-1- te,t-iLr3
Address ...-.
re Name of Funeral Firm Making Disposition or to Whom
....:•: Remains are Shipped, If Other than Above
Address
. 1i Permission is hereby granted to dispose of the human remains described above a indicated.
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Date Issued /424/3, Registrar of Vital Statistics q wolf 07
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( gnature)
P4 District Number qt)62. Place ,j6-1 kcyNoLbs joD do C:'..Au NV 1425..0
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
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; Date of Disposition 14-11.0 Place of Disposition
(address)
141
51)
(section) Ailio)tix..-n mber) (grave number)
l'8 Name of Sexton or Person in ChargTof Premises
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..._ Jr-.7-- (please print)
• Signature Title Cariwyniza.
(over)
DOH-1555 (9/98)
•