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Dever Jr, George NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Vital Records SAection Se. //) Middle Last Name St CC'L� Date�f Death Age If Vete n of U.S. A med F ces, Gnu War or Dates titution or Place of Death Hospital, Ins �� City, Town or Village Street Address Undetermined Pendi Manner of Death Natural Cause Accident Homicide Suicide ❑Circumstances Investigation Title 4. Medical Certifier Name Address ». District umber Death Certificate Filed _ ©/ Register Number City, Town or Village Cem e yr Cre ry Date ❑Burial Address V�. emation Date Pla emoved Removal and or Held ,... and/or Address Hold Date Point of Q Shipment N❑Transportation by Common Destination Carrier Cemetery Address Date Disinterment Date Cemetery Address Reinterment Registration Num r Permit Issued to Name of Funeral Home h s Address Name of Funeral FiFm Making Disposition or to m Remains are Shipped, If Other than Above Address rmissio i hereby granted to dispose of the human remains des ri/bedf above as i ica ed. <:> Pe t}g Date Is ( Registrar of Vital Statistics (sign re) District Number r Place -l1 that the remains of the decedent identified above were disposed of in accordanc ith this permit on: I certify Place of Dispositionv '� ' F Date of Disposition (address) (section) (lot n m er) ave number) 27 QName of Sexton or Perso in Charge of Premises (please print) S'947 �7 Title III W Signature (over) DOH-1555 (9/98)