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Shanley, Julie NEW YORK STATE DEPARTMENT OF HEALTH tt zl Vital Records Section s ti Burial - Transit Permit iiin Name First — Mi die Est Sex U L i G� treA16[_ F-6)'1 f : a Date of Death A e If Veteran of U.S.Armed F rcp / l& 1 Z glf�p War or Dates �jjr" P e of DeathG\466."-LS Hos ital In. t on or C own or Village F'L[ S treetAdd /,� � f'. .3 Ed anner of Death Natural Cause 0 Accident 0 Homicide Q Suicide determined ri Pending Circumstances Investigation ut Medical Certifier Name Title 41 /2'UL b'-/y /0 Address Certificate Filed District Number Reigist Number tt City • nor Village p 616-7,,iS Fijits rem5 6o ) LI S' mi I Burial Date Cemetery Catory M..,j a...., ij, 672_3 ❑Entombment Address Cremation U d �"YAy ZC ` _ U614- SQ Date Place Removed 7 Removal and/or Held and/or Address Hold Date Point of 0 Transportation Shipment by Common Destination Carrier Q Disinterment Date Cemetery Address • El Renterment Date Cemetery Address ,enAB Permit issued to Registration Number Name of Funeral Home 1,40100f8 '0, 1:er ¶unerci.I ')tr.... ©l 130 Address Name of Funeral Firm Making Disposition or to Whom 14 Remains are Shipped, If Other than Above Address Permission is hereby granted to dispose of the human remains described above as indicated. <' Date Issued -) 3) j 2 Registrar of Vital Statistics LJ,) -A;a"- ilp ) (signature) ii District Number 5 601 Place .0 � )5� ' , S /`V y I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: k. iti 1 Place of Disposition 1;11-(Ukcs, l�ro-ei0,ig.1..� Date of Disposition too_ P (address) i lZ (section) 4-,..„...; (lotnumber) (grave number) Name of Sexton or Pers in Charge of remises `� 1.001... (please print) >::. Signature Title Ce. M for iC'1L (over) DOH-1555 (02/2004)