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Cudney, Dudley NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First .�.a Middle � `Last Sex « Date of Death Age If Veteran of U.S. Arme orces, �a ) 'A 17 War or Dates L, ✓ j o Place of Death Hospital, Institution or City, Town or Village 6; a�o S Street Address ufK�a ZE] Manner of Death©Natura au e Ac e t [�Homicide Suicide Undet minedPending CircumstancesInvestigation Medical Certifier a Title Address a I If ��� � s C� ti�� N. is ! ;k'6 Death Certificate Filed Yistrict Number Register Number . City, Town or VillageC, Date U Cemetery or Crematory ❑Burial LA 3 E; Address Cremation `�©t e b " Date Place Removed 0❑Removal and/or Held �. and/or Address Hold Date Point of F�Transportation Shipment by Common Destination Carrier Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home �.�L 4 1,,C C9 0 Address Name of Funeral Firm Making Disposition or to hom Remains are Shipped, If Other than Above Address Permission is hereby granted to dispose of the human rem ai c ed abov sin icated. Date Issued 10/?,kji7 Registrar of Vital Statistics (signature) District Number Placeol I certify that the remains of the decedent identif d above were disposed of in accordance with this permit on:A� W Date of Disposition ' - Place of Disposition /jV (address) w t/J (section) r� (lot number f (grave number) Name of Sexto or Person in Charge oLRemises A/1 ,� lr/ .(please print) t`�-- 1� Signature Title r✓ /lam✓ 4 �%/ DOH-1555 (10/89) p. 1 of 2 VS-61