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Rockwell, Marcia
NEW YORK STATE DEPARTMENT OF HEALTH ISO Vital Records Section Burial - Transit Permit Name First Middle Sex�i42rq /2oc c/f F Date of Death Age If Veteran of U.S. Armed Forces, 034,5-12.rJ/ I-- /' War or Dates l-- P e of Death �/ / Hospital, Institution or / r/ ,( City,' wn or Village �Piy�o /�6� Street Address 6/.-Gyw A-7X A6V—✓7 a ner of Death1Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending La Circumstances Investigation uj Medical Certifier Name Title is (-'X�4;o /47 , , ,0 Address 7a 2 , , 5/2 6/e,„, 4,A, /ox Death Certificate Filed z/� `j District Number �/ Register Number City, Town or Village 6A > / ❑Burial Date ©3//fir�24/� Cemetery or Crematory 4,,,/ry (-7,,a.t, El Entombment Address Cremation (.;7e/c'e.uuLi._y, Ay Date Place Removed ❑Removal and/or Held 14. and/or Address I= Hold C 0 Date Point of Transportation Shipment L1 by Common Destination Carrier Disinterment Date Cemetery Address Reinterment Date . Cemetery Address Permit Issued to �� j Registration Number Name of Funeral Home /�Yii�o/lu4)e / �NP2ax `1� �a 5/8' Address ,,y� Name of Funeral Firm Making Disposition or to Whom / Remains are Shipped, If Other than Above Address in Permission is hereby granted to dispose of the human remains describe abov as'ndi Date Issued 3 !6 .20/-2— Registrar of Vital Statistics �� �. © / (signature) District Number 60) Place lr/-�) AA /V/ .: I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: k U Date of Disposition 3>i q_�ot2 Place of Disposition I 1 rie the , C re meeta. .'u wI iM _ , address) ua to I t'fv70 t/ i.)r(te_ CC (section) r (lot number) (grave number) ta Name of Sexton or Person in Cha ge of Premises 2 ----- (please print) Signature rryW. 4 4. Title i erh a4aty 4'/ (over) DOH-1555 (02/2004)