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Lane, Girard C NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Vital Records Section Name A Middle ex � List `rar d............... �:::::. L.u✓1e.... Mc1.�� . Date of Death Age p If Veteran of U S.Ar ed Forces F-•..: :,1�4 fi ::.7 t .:t.Q� ............... ......... ....... War or Dates GYP .... _....... _...... ....... ..... .. Z Place of Death Hospital Institution r L W City Town or Village Gl is Falls Street Address ��e{/iS �rc��S IjiSPI>�iiJ f� Manner of Death M Natural Cause ❑ Accident Homicide ❑ Suicide Undetermined 0 Pending W tLCL1J Circumstances Investigation .. ....: :..... .::....... .......................... . Medical Certifier Na Title © clef i6t6d' D Addr ss .. `�af►� S ee f CI S{er �z�t kl Death Certificate Filed istrict Number Register Number City,Town or Village 61116rb J�Ctlk Date Ce etery or Crematory ❑Burial . [�Cremation Addrrps we Nu) C t �ir�G l✓f�t.h L Z Date Place Removed O ❑ Removal and/or Held I. and/or Hold :.:A. :,.. ..... ........ _..- Add res s u7 o ............. ......... ....... __ n a Date Point of cn []Transportation by Shipment Ei Common Carrier .......... .:... Destination .... .::...::........... _ .....: _.:_ _ ...........:..... ❑ Disinterment Date Cemetery Address . .::- ❑ Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral FirmG(v>tG� �(LDe��nUf�" r!%t6i�tCf( 1�h a-y►.� _._ d�� Address � ....5� .::.:CGtgS��cwn t /I�: - 11 . t— Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above ............................................... ._.. ......... ...... :......:::-:::Address _,.... U: o Permission is hereby granted to dispose of the hum remainns described above as indicated. Date Issued 6IJ- ( Registrar of Vital Statistics yt J/ L`Cib�i�1% (signature) District Number �C�C'I Place , �:Le,,s Fit I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W;; Date of Disposition Z / J Place of Disposition /�zr,Cllc� LC� 2; (address) LLI Cn (section) (lot number) (grave number) cc o' Name of Sexton Person;inarge of Premisi�Gy ���i9�L/ W (Please print) � Signature Title DOH-1555 (10/89) p. 1 of 2 VS-61