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Rivera, William NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First // Middle Date of Death G Age If Veteran of U.S. Armed Forces, _ �� � �.� .� © War or Dates )'tom Place of Death Hospital, Institution or City, T-ewR &F Village Street Address Manner of Death Natural Cause Accident Homicide Suicide ndetermined ❑Pending A. Circumstances Investigation Medical Ceti r e Title M,D, Death Certificate Filed -y District Number Register Number City, Tn"ura eF-Village .3 Date Cem ry or Crematory ❑Burial /9 g.�" el r JX Cremation Adess YJ FDate Place Removed Z ❑Removal and/or Held and/or Address Hold Q Date Point of N Q Transportation Shipment by Common Destination Carrier ❑Disinterment Date Cemetery Address ❑Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home — p! G �-t . (�u G� 42 �. Address01 / /7 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address Permission is hereby granted gqttoggdispose of the human rem ai s described above/ads indicated. Date Issued —2 /y//'F��"gistrar of Vital Statistics (signature) 'Z-� ) District Number Place I certify that the remains of the decedent identified above were disposed of in accordarKe with this(lermit on: 2�,''//�� Date of Disposition�Z1 L Place of Disposition �/t�.E� + !address) UJI ( t ) '� � �(lot nm A (grave number) Name of Sexton r Person i Charge of P mises ,L`'� (J /f (please print) r Signature Title DOH-1555 (10/89) p. 1 of 2 VS-61