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I B�.DATE [Ma.,Day,Yr.] ' i <br /> �R�� ❑W7�pn N'v� Emb a]�aed � rrr Au��ir ��� �4/�� • <br /> 1�Cram��n C]E�fambment ��G���=�REMAT�RY�H ATH�R LOCATION CITY f TD'WAi STATE <br /> . � <br /> I <br /> i <br /> ❑Remaval C�ther(Spacl�y� We s t�awn l�exa�r ial P a�r� C r emat ory, Grand �s land,, 11�E � <br /> � <br /> ` 11�.FUNERA�.HDME NAINE�A1D hflAli.INa ADDR�5S (5treet,Ci�r orTown,S'iste] ��b•Zip Code ' <br /> . _-5; Apf�1 Fun�ral Ho�ae, �1123 T�1'est 5eco�sd, Grand Is1�.nd, 1�'E. 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Y'� �I UnkrtQvvn 1�prsgr�ant wtt�n the p�st year r.Y�3 �1 Af 0 <br /> � <br /> . ;� � <br /> 2�a.DATE��1NJURY(Ma.�i]ay,Yr.y �b.TlME DF iN.f�HY �a.PUtCE[]F iN�lUAII-At[��ms,f�rm,str�t,fa�tary,offic��uflding,cansfruct[ar�s�e,etc.{Spe�Ify� <br />, m � <br /> F � <br /> �a.�NauRrArwraax� �e.oEscRi��How inwuRv occuAAEn � � <br /> f <br />, ❑�rEs p Ko � <br />, � <br /> 2�f.LOCATION�1hWURY-BTREET&NUMSER,�4PT.Na. C�fY�I'OV�iN S"fATE IIP i,'QOE • <br /> - ---'- ~c -- '- �- -- -- - -'--- -- - -4-_�_-•--- _._ _ -- - -- -.,�_- - -�-'- _-_-.-.--�__�_`.___-.��_ -�- �_��� <br /> p . I <br />� � �` � �3a.DATE[7�DEATH(i�o.,Day,Yr.� �4a.OATE 31CiNED�Ma.i]ay,Yr.� �a�.-��E o�r�rH b�, W n ' <br /> , <br /> �f�. ,�� 1�:�0 am - :�� m <br /> � <br /> � - ! <br /> 23b.DATE 8laNEi3(Ma.,Day,Y!.] �c.TlA�E OF D�ATH � �4c.PRDNDUNCED DEAD�Mo..Day�'Yr.] 24d.T1�IE FR�11�?i11�CED DF..AD <br /> �7�� � m ��� �, � � <br /> � ��O w � <br /> �3d.Ta the i�ss!of nty[uwwl�dg�,�aath�ccurr$d at tY�e�me,date end piace � . n s a�s � r��n an ar nvss�ga'�an,in my opinIon deatt�ocGurrs�[a3 , <br /> ' •-��.�i 6�C�ti duB to t1re Cau88 B�t3ed. Si�a�u�e 6�1�Tf�l� ■ �� !h�t� tlPt ^��' "" ' a t4� �se(s}st�ts�[Rt���ure and Title�� <br /> -�-� v . f� � � � ��� � � <br /> ~ ~8� �� . Deputy . , <br /> 1 Ha�3 Count Att rne� <br /> � <br />' ' ?�.Dl�7�BACCO USECONTRIBUTE'fdTH�D�AITH? �8�.H�15 OflG14N OA TiSS11E D4NAT�DN i��N C�NSID�EDT y��3 CQNSENT OHANTED? � <br /> � ; <br /> �? ❑YES ❑ND ❑PRQBABI.Y �1 L]NKNQWN ❑YES 1�NO t l�t�li�gble i#�6a is N❑ ❑Y�8 ❑NO <br /> 2T.NAA��TITLE ANR A01]RESS 4�CERTIFl�R(PHYS[ClAN,CORf3N�R'S PHY3ICUIN 4R(�UMY ATTDRNEY���r Prl�t <br /> �� � • � Deputy Ha�3 Caunty Attorne�, 2 l S. Lo�ust St., G�and Is1and, N � <br /> � K� s o 1 � <br /> _ , <br /> 28a.FlEQ[S'�RAR°55i[31V�4'�U�E � z �, 28�.DATE F1��D 9Y REQISTRAR��lo.,DayTYr.) <br /> F ,�� . ���I <br /> �U� �� 2QQ9 , <br /> � <br /> . , <br /> � <br /> . , <br /> . , <br /> r HHS-B1 i 1f03��5Q61) � <br /> � <br /> . I <br />