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Doan, Nancy NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last �--� Sex �© Dated Death Age i If Veteran of U.S. Armed Forces, War or Dates Place of Death Hospital, Institution z5r?�eryuyR City, Town or Village Street Address Jj , Manner of Death atural Cause Accident Homicide Suicide Undetermined Pending Circumstances Investigation Medical Certifier N e / Title 4.7 �J Co Address Death Certificate Filed District Nu ister Nur6ber r> City, Town or Village / , p Date Ce etery or Crematory ❑Burial 'e' c"A Address Cremation S��S Date -T-P ace Removed ❑Removal and/or Held and/or Address Hold Q Date Point of Q Transportation Shipment by Common Destination Carrier Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to �— Registration Number Name of Funeral Home Address /Q /t'j c Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address Permission is hereby granted to dispose of the human remains d cribed above as indicated. Date Issued %f Registrar of Vital Statistics �. (signature) District Number / Place I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: f... �`Date of Disposition-1 1W Place of Disposition r'�205 (address) i cc (section) (lot number) (grave number) D Name of Sexton or Perso in Charge of Prises � z (please print) r LU Signature Title /� QLLL SSj DOH-1555 (10/89) p. i of 2 VS-61