Moses, Clara NEW YORK STATE DEPARTMENT OF HEALTH__ , f S* `1
Vital Records Section Burial - Transit Permit
> Name F r t Middle Last Sex
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Date of Death Age If Veteran of U.S. Armed Forces,
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14. Place ath Hospital, Institution or
Cit ownbr Village —TTCZA,)cilt-c J A Street Address &loses Lvd.r' 7.- /uvrsifi7 j4/ i...
• Manner of Death Fri :Aural Cause 0 Accident 0 Homicide El Suicide El Undetermined D Pending
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Circumstances Investigation
.a Medical Certifier Name Title
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Death Certificate Filed Distric'f Number Registf Number
City, Town or Village co u,1 d_q ,5 45G y (r� .5
><>0 Burial Date Cem ery or Crematory
iice./i eiti 6,2_07pT>�`
❑Entombment Address ad)e.Qiul_!:
Cremation : cbC,Vy NT • IS(16
Date Place Removed
'Z ni Removal and/or Held
14 and/or Address
F- Hold
old
C. Date Point of
vLiTransportation Shipment
0 by Common Destination
Carrier
Q Disinterment Date Cemetery Address iii
El Reinterment Date Cemetery Address
Permit Issued to /� / Registration Number
: r Name of Funeral Home Jwro v-�- j, K / roIj)erA/ J/Q 2_ OBS`/q
AddressSC-11--0-e-y\__
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Name of Funeral Firm Making Disposition or to Whom
14 Remains are Shipped, If Other than Above
:: Address
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f3 Permission is hereby granted to dispose of the human re ins described above as indicated.
Date Issued /07/3/2/. .Registrar of Vital Statistics m ' Z
(signature)
iiM District Number /56, Place / j Cord cie 5_a, A-}7
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
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iii Date of Disposition I0-1-1-I Z Place of Disposition -g4 i)tNi 6446N-
2 (address)
C (section) (lot number (grave number)
i. Name of Sexton or Pe on in Char a of Premises Aqiyit_. P.,�+4.
z (please print)
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Si gnature Title ( Z rZ
(over)
DOH-1555 (02/2004)