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BLOCK 13 LOTS Z and 2
UNIT #2 DEED #392
Vernon W. or Gertrude A. Combes
7945 Brevard Avenue
Roseland
Vernon tid. Combes interred Lot 2- 3/7/89
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DEED #392
Paid by General Receipt No. . 178 . . . . . . . . . . . . Dated. .4/3/�0 . . . . . . . . . . . . . . . . . . . COMBES, Vernon W. or Gertrude
L,ist Price �.*.*.200..O.Q.*.*... Masimum No. Burial spaces .....2...... �945 Brevard Avenue
Roseland, F1 33957
Discount $.... -............ Total area in square fcet ................
Net Paid $**?D0,..00**.,, Monument permitted ...f.Zat............ BLK 13 LOTS '�&2 UNIT #2
(Data above Yhis line for City R.ecord only)
R&R attached _
Name ���%r�i/e � TT � n,�i'� ��:,,. � �,� � ' � L7X:�
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Lot /
Date of Mark-out 4U..��/�� Z--
Date of Burial
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NEW YORK STATE DEPARTMENT OF HEALTH �/ 2,
vita� Records section Burial - Transit Permit
::;' Name First Middle Last Sex
QOI��ES
:::;: Date of Death Age If Veteran of U.S. Armed Forces,
94 War or Dates �
<'' Place of Death Hospital, Institution or
City, Town or Village �verhead Street Address Riverhead IJurs'
;.� Manner of Death a Natural Cause � Accident � Homicide � Suicide � Undetermined � Pending
Circumstances Investigation
���: Medical Certifier Name Title
Devendra K. Si h
Address
91 Bay Avenue, East Moribl�es, New York 11
::;:: Death Certificate Filed District Number Register Number
:'<::: City, Town or Village �-v��� 5155 2q2
c—� Date Cemetery or Crematory
`'� R� � Burial June 27. 2002 Sebastian Cemetery
Address
�`? ❑ Cremation Sebastian, Florida 32958
Date Place Removed
� ❑ Removal and/or Held
•... and/or Address
�" Hold
�
Q Date Point of
y� Transportation Shipment
� by Common Destination
Carrier
::: � Disinterment Date Cemetery Address
: � � Reinterment Date Cemetery Address
;:>' Permit Issued to Registration Number
:>< Name of Funeral Home �J- ��u91'v-in �neral Home pp�pp
;;> Address 336 Marcy Avenue, �ive�� New York
�::> Name of Funeral Firm Making Disposition or to Whom
�� Remains are Shipped, If Other than Above Stcunk Funeral Home
Address
1623 North CenreL Avenue, Sebastian,F 'da 32958
:�
::: Permission is hereby granted to dispose of the hum re ai describe ove indicated.
�:<s Date Issued ���/02 Registrar of Vital Statistic
(signature)
::> District Number 5155 Place ARiverhead, New York
�: I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
� �
� Date of Disposition a� o Place of Disposition / �!7 ' ,� �
,�,�+ (address) .
� �f✓.T`� . �� •�� ���
� (sectio ) (lot number) (grave number)
� Name of Sexton or Person in Charge of Premises ,�,��, �,�� �� Ti� .
� � (pleas pri t) � .�—
� Signature ' Title � �','►�/ O i� .
(over)
DOH-1555 (9/98)