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Drexhagen, Helen NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Vital Records Section Name First ((( Middl Last Sex EI erJ �`�......:: - .. '�'`::.::::_ .. .. ....... �-- Date of Death Age If Ve eran of*U.S.'S Armed Forces ��E<f 7r-*�::. _ War or Datesnl :. 9 ZPlace of Death Hospital Institution or Uj CitY 'c. AiZA-Tc;7. ... !N Street Address '��it... Manner of Death. ::: .. . .:::.......:.. _::. :... Undetermined Pending w, Natural Cause Accident Homicide Suicide _.... .................................... ..:............. . ......: Circumstances Investigation t3 _. W Medical Certifier Name Title © US fart S .......:....... .::..: ..::..... Add res q Spa, w r-t--r.� . ..... . .... � _ ..: k ..... Death Certificate Filed istrict Number Register Number City,Town or Village 4501 Date Cemetery or CremMe El Burial i �7 ©© .. Cremation � Address u� � j .' Z Date Place Removed O Removal and/or Held F and/or Hold :::.... :... ...... ......... .-:..... ........... . ..-.: ......:..:: Address N 0........: ....: _...: -... ...:... ......... ::... _:: . .:::: :.....:..:. . ............ ::: _... ... ......... a Date Point of to Transportation by': Shipment Common Carrier .......... . .. ......... . -.::::.. . ...... -. ...........:: Destination .... .. .:::::::.. :::...:.... ........,. .._....... Disinterment Date CemeteryAddress El Reinterment Date Cemetery Address Permit Issued to / Registration Number Name of Funeral Firm .. ., k X�1a'c�� �/(� ,�}f /f �f C � '� 4�E' ..:.:... .... _,:... . Address /l y..:r'�lgi1efZ.. c/S �r� /t!o'.../, .......... ... . ...... ..... . .......................... ......:............ . Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address a Permission is hereby granted to dispose of the human remains described aboxa as indicated. Date Issued -2 12Z93 Registrar of Vital Statistics 'n JQ=nt ' (sig District Number 4501 Place Saratoga Springs,NY. I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z Date of Disposition �t .3 Place of Disposition / /�.�1�/•��/ ��•��/4 Tom/�� w (address) 2 w Cl)'' (section) (lot number) (grave number) cc 'p Name of Sexton or Person in Charge of Premises Z A4, (please print) l-7—� W Signature Title ����L�r/PV �/ DOH-1555 (10/89) p. 1 of 2 VS-61