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Burch, Pearl NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name Firsts Middle Last Sex Date o D ath Age If Veteran of U.S. Armed Forces, War or Dates Place of Death Hospital, Institution or City, Tavtn-©x-Vfitage , Street Address Manner of Death Natural Cause ❑Accident ❑Homicide ❑Suicide Undetermined Pending Circumstances Investigation Medical Certifier amp Title ./ ddress [ Death Certificate Filed District-Nm b er Register Number 1 City, Town or Village (�, fir✓ (� Date ' C etery or Crem tory ❑Burial , tLloL.a Wy Address Cremation �, � 8 Date Place Removed Z ❑Removal and/or Held �• and/or Address Hold Q Date Point of y Transportation Shipment d by Common Destination Carrier Disinterment Date Cemetery Address • '' Date Cemetery Address Reinterment Permit Issued to r�,,, Registration Number Name of Funeral Home .J l�.cc � ?,r - C_ 001)I Address12g y� '/ Name of Funeral Firm Making Disp sition or to WhorrO Remains are Shipped, If Other than Above Address Permission is hereby granted to dispose of the human remains described above as indica ad. Date Issued jCj Registrar of Vital Statistics (s1ignatur District NumberR '_ O( Place -A-V d��� /l(. I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W Date of Disposition `�b Place of Disposition ! .� ,�� c�i�/��/�✓/l I /v/ ..2 (address) LU N f>E (section") �,Q (lot tuber) & ) (grave number) GName of Sexton or Person in Charge of emises 939 J/��.1> j�T�i �c/ g (please print) Signature Title DOH-1555 (10/89) p. 1 of 2 VS-61