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Shoemaker III, George zy NEW YORK STATE DEPARTMENT OF HEALTH e --L-" 5 7 Vital Records Section Burial - Transit Permit Name First Middle Last Sex Gia e_ ID ` _ ho .k _, -+ IADate of 'Death Age _ If Veteran of U.S. Armed Forces, ` 10 I o1`i ' j L Z. 1__-___tp i__--_ War or Dates m `"i t —I q 7 5 __ f- Place of Death Hospital, Institution or W City, Town or Village 1c j n � Street Address j8 Q rvy 55 i r CA _ Q Manner of Death©'Natural(tause Accident 0 Homicide 0 Suicide Undetermined Pending Circumstances Investigation W Medical Certifier Name Title Address _a 7 6-04A in 51- ' ,av ve is b Ltrg. N 1_2-8 5 Death Certificate Filed I District Number ' Register Number U / City, Town or Village Kt n s bi ly� b 7 y'a` i / 5 Date Ce etery or Crematory C urial ►o.i lit- V_ne vac. y ❑Entombmen , tf -- - - -.. - Add ess Cremation to R.4., _Dive e rb b u try Ny 12 80 u Date f Place Removed ❑r-i Removal j _i and/or Held 2 and/or ----_______----__ - --- -- --_ --------- t- Address Holdth - -0 Date Point of NQ Transportation L Shipment a by Common I Destination Carrier Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to I Registration Number Name of Funeral Home 1•4 0,,I ncu d '�. 60,ker ;_n a.I kit)rr% CLP0._ Address I I L atCky Q. H C- i • , (;)L.L.CC mbar v , N C v� 'Yu IL a. L y Name of Funeral Firm Making Disposition or to Whom I- Remains are Shipped, If Other than Above 2 Address IX W tl' Permission is hereby granted to dispose of the human mains described above as indicated. Date Issued l0 • < '.)0/2 Registrar of Vital Statistics r CD) (signature) District Number 5-76a_ Place / „ I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: WDate of Disposition ic)3oi t1. Place of Disposition ,404,,J — L rehr;/t r...— -- (address) — W — — — — -- re (section) (lot number . (grave number) pName of Sexton or Person in Ch rge of Premises - Ar.11p�se print)l�.ii- 2 W Signature -_ Title Ceteivi , ____._ (over) DOH-1555 (02/2004)