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Towers, Stephen M. NEW YORK STATE DEPARTMENT OF HEALTH I Ii 0 Vital Records Section - 4 Burial - Transit Permit Name s addle Last Sex �-epL� 16 Date of Death Age If Veteran of U.S. Armed orces, D 1 c\-C..I .(JcO `--) cp. War or Dates I-- Place of Death Hospital, Institution or n W City town°Q Village Q 1.� e•'.� Street Address LI L( 1L.).I k -�u`�cgcx�,,►� in G Manr r VDeath Etlatural Cause El Aqjlent u Homicide 0 Suicide IT Undetermined ❑Pending inCircumstances Investigation W Medical Certifi j2,Name Title Crc �tc Ali., Add ( >- 0 l Death rt ficate Filed (!: � Dist �mer Rega�te�Number Cit , Town oryillage � ll CC"1 ❑Bursa Date t .ietery or Crem ory DEntombment 1 © ( e"') ( aC`) '-"t tm U k ?L) L-1 ,D\Ck� Ad s Cremation v c.I�-(ZC�c��A �k.��r k-i��1 n i 1 At) --, Date Place Removed ❑Removal and/or Held and/or Address t Hold to O Date Point of ti❑Transportation Shipment O by Common Destination Carrier El Disinterment Date Cemetery Address ❑Reinterment Date Cemetery Address Permit Issued to I' Registration Nuipber Name of Funeral Homed e4 ,,,tJf� �c4er� -+-t.^�) �., G0 `--t Address r FA Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above • Address cr t .' Permission is hereby granted to dispose of the human remains describe/ �(� ,}S� Gam., -� d above as indicated. Date Issued � , diegistrar of Vital Statistics -- Q U r, ---...___ (signature) District Number )c -) Place i U�2 ,rti c -,n h I certify that the remains of the decedent identified above were disposed of in accorcice l h this permit on: ILI A. of Disposition o Place of Disposition ,,,,,j�.� � �t b'-- • Date p lobo�� P (address) W CO (section) (Ioo 1 umber) ` (grave number) Name of Sexton or Pers in Charge Premises I'r.s �"'-�NA (please int) L i (*mot. .: Signature Title (over) DOH-1555 (02/2004) Public Health Law Sec. 4145(2b) 0 1 416? Receipt Human remains of `' Z. delivered on - , 20 • . - Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License# ,"