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Fuller, Laurence NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First rMiddle Last Sex �^ enc �. Cam.. /_ 1 's Date of Death, Age If Veteran of U.S. Armed Forces, A� �5 War or Dates Place o th - Hospital, Institution or City n o Village Street Address S� �abr:e L ka . Manner of Death©Nat ral Cause Accident Homicide Suicide ElUndetermined Pending Circumstances Investigation Medical Certifier Nam Title Addres Death C icate Filed District Number Register Number ` City, nor iilage r. 1L 4? >5 Date C etery or Crem tory ❑Burial 17 i �v,` w /e—'t Address Cremation Date Place Removed Removal and/or Held and/or Address Hold Date Point of OF-1 Transportation Shipment by Common Destination Carrier Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Address 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 re aLis es i d ab ve as indi ted. Date Issued 7 Registrar of Vital Statistics {s 27 ire) District Number S Plac dm�A-tl I certify that the remains of the decedent identified above were qvposed of in accordance with this permit on: r Date of Disposition Place of Disposition Jti�iil,Fli/�.EJGJ �.�A1 T/Ini� (address) (section) (lot number)/ (grave number) Name of Sexton or Person in Charge of Premises / " (please print) Signature Title DOH-1555 (10/89) p. 1 of 2 VS-61