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Palmer, Roy NEW YORK STATE DEPARTMENT OF HEALTH 7 Vital Records Section Burial - Transit Permit 14.......,—,...0Name FirstMiddle ` � �� Sex i N0,� 1 Jam( Date of Death Age If Veteran of U.S. Armed Forces, ©7 2 9-7�1 z (� War or Dates 1.4 lace of Death Hospital, Institution or ] '' I ity,Jown or Village (1)./- Street Address £j'-4iv-I' k0 ,1 a nner of DeathONatural Cause O Accident Homicide Suicide Undetermined Pending U ��--'' Circumstances Investigation iti Medical Certifier Name ^ Title slit 44. _Sbs Pal t$11Nbu Address ' i %- . D-. Certificate Filed / District Num_r Regisir Number own or Village. COP („ a j J -9'd / S(g 11.2 OBurial Dateetery priCrematgry. 07 0- o t''-_ 4 1 VA&..� I.-1 13 a V s i DEntombment Addees �N-, o remation t4i1Ck-ve.v` (tsiF is / 1 Z Sol • Date / Place Removed Z Removal and/or Held {?O and/or Address fib Hold 0 Date Point of t Transportation Shipment C by Common Destination Carrier El Disinterment Date Cemetery Address El Reinterment Date Cemetery Address ,iniiii Permit Issued to )��M� �" Registration Number Name of Funeral Home U-�� h'r L rk,ik- h Ov'i' G I d-7 9 Address Z t.r1-0,ou,t4de ' / t.t�its.) ,�� �>` l 1.--P2 on imi Name of Funeral Firm Making Disposition or to Whom • Remains are Shipped, If Other than Above ,', Address I w . ` Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 9im _1 i 'O,12 Registrar of Vital Statistics GO Cu `� ( tune) ipii District Number .56)% Place l c fey-bi r23/ I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: pDate of Disposition 1!Olt Place of Disposition • ,nVoW 6*rit, 2 (address) Lu i ix (section) _ (lot number}- (grave number) o Name of Sexton or Person in Char a of Premises �ru e"'ril Z (please print) ::K Signature Title otemik,ot (over) DOH-1555 (02/2004)