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Pigon, Dorthy NEW YORK STATE DEPARTMENT OF HEAUM Burial - Transit Permit Vital Records Section Name -"Fir Middle Sex :... ...�...:: ..................... a ..............................:...;..... . . .. Date YfVeat ath Age If Veteran of U S d Forces War or Dates Place Hospital Instit i or :Lti City Town or Villa �' Street Address ( ` ; .;�- �r� t.-�:ca ,-. :1r�c.P-. ........:..,. ....... v�c . ��+.-.. Q; Manner of Death Natural Cause Accident Homicide Suicide Undetermined Pending ❑ ❑ Circumstances Investigation ....... _ ................. W Medical Certrf r Name �i`Title 0.......... d... ....:. ..E. -a...:�.. ..ors ..... ....1....1 �. ..�....................: . ..:......: ...:............................... ... ... .......... Address .. ... Death Certificate Filedd District Number Register Number » City,Town or Viler Datd C meter�l!��r Crematory ❑Burial ` .l.... ..�.,.. ... �,...., - !1 ,X ...0 ::..� .... ...... 41 G.. �.:: .. ter+ .\` , Cremation ' - ddress / G- '.^.tea-.�'h.:.. '.III .4::��. ` `........... ................ ..- Z Date 4 e Removed 0, ❑ Removal and/or Held I— and/or Hold :::...: ... ....... -_::: ..:::: Address 0........................ ....:..:::...:...... .. .............. .....:. . .....::.:..................... ....................... ......... a Date Point of cn ❑Transportation by ` Shipment p; Common Carrier ............................. . - ........ .............................................................. ..........:...........,,......... Destination ......................... .......................... .....: .:.. ....... ._........ ........_... ❑ Disinterment Date Cemetery Address ...... ...:.... _.:::.:....:........:..... . ::::......: _ :,: ❑ Reinterment Date Cemetery Address Permit Issued to ` Registration Number Name of Funeral Firm ate, _.... ............... A¢dmss Z F- Name of Funeral Firm IV�aking Disposition or to Whom \ Remains are Shipped, If Other than Above .... , ... ........-...................... ............:..:: .......... . -................ _.......... _............--_.:... .................................:......................... W: Address Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 90 Registrar of Vital Statistics ignature) ` District Number Plac \:� - I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z Date of Disposition / �J © Place of Disposition A1�.CC W (address) 2 >.w N (section) (lot number) (grave number) cc pName of Sexton r Person in harge of Premises Z (please print) u1 Signature Title /6/�/7/ DOH-1555 (10/89) p. 1 of 2 VS-61