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Morgan, Twin B NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transi ��rmit Vital Records Section s Name First -th,J IJ tk�i' Middle Last 0R Sex ✓ Date of Death Age If Veteran of U.S. Armed Forces, (0 -11.-l - - — rDates 14. Place of Death ospita Institution or lL QV Town or Village Autg2j j,y eet Address 1-J/ ,� Wks- j anner of Death ET/Natural Cause El Accident Homicide El Suicide Undetermined �Pending W. Circumstances Investigation tki Medical Certifier -Nile Title l t �► Addressvii ion, ek4,...rf4i,. 4.1.zittii Aiv -.th Certificate Filed A „ � District Number Register Number <; Town or Village f-1_t' <:»' ■Burial Date Cemetery r, a)tory vrti imi❑Entombment I©�� ,��� we V) iiiiiiiii Address ( CN>kt�RID,,___CF4635%�Y M)/ Z`?o�Cremation a Date Place Removed ,E �Removal and/or Held ler and/or Address W� Hold 0 0 Date Point of Transportation Shipment i by Common Destination Carrier i Disinterment Date Cemetery Address s Q Reinterment Date Cemetery Address Permit Issued to 11nn�� �/ Registration Number Name of Funeral Home I iAi; f 1)i-vki*- �Idp — 01078 Address V ililw - Sts , a k ,,, /v v i. '., . Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address !C tip Permission is hereby granted to dispose of the remains described above as indicated. iiiIiii Date Issued I 0-1Z-2pl'---Registrar of Vital Sta ff - (signature) RA District Number tot Place al d OF Pa,MN I certify that the remains of the decedent identified above were disposed of in accordan with this permit on: k III Date of Disposition 10-19- 12- Place of Disposition ?'Inc Jj'eL) C.(-ei.ejar:vo) 2 (address) ta (s ) (lot number) (grave number) Name of Sexton or Person in Char e of Premises r`j'''1� ne(k 24 • I (please print) Signature Title Crer 4c,Ro 4' (over) DOH-1555 (02/2004)