Gagne, Norman NEW YORK STATE DEPARTMENT OF HEALTH 1$'`i
Vital Records Section Burial - Transit Permit
Name First Middle i Last Sex
ga.m ) Rt')NRtL �.RGNV., t1I AL
Date of Death Age Veteran of U...i. Armed Forces,
AP(Z‘L An , -00(0 (/0D War or Dates v r_,--T E A Pv\
Place of Death Hospital, Institution or
-6tty, Town or-AI-Wage
LAKE C-- pR Street Address 1 . ,t3( Rai AU E .
0 Manner of Death pNatural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
W. Circumstances Investigation
Ca
in Medical Certifier Name Title
12. mFf 57 (2)R.ce NI IN)57
Address
316' B1N --� N,&.BL. G m� lag
Death Certificate Filed District Number Register Number
`; -Gity, Town or-Viltago LAkE C- n2('-TE.
❑Burial Date Crematory
PIL 660 l� \ IE5� ' b❑Entombment
Address
pi !c remation QU A ft,, (kGtn�SE ,u "�1 � 1 a11"
Date Pla a Removed
Z ri❑Removal and/or Held
9. and/or Address
F" Hold
46
0 Date Point of
0 Li Transportation Shipment
ea by Common Destination
O Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home 8-; r, Va voFfeAl kyvvf. 1`l C, CD-1 I U
Address
9 D TA z/72k1Av` LA _ QG-.) \i
1 a g s'
Name of Funeral Firm Making Disposition of E to Whom
Remains are Shipped, If Other than Above
';; Address
t
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CL
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued i / 7/da Registrar of Vital Statistics et ",J r cf1/4. .0
(signature)
Ei District Number &G ( Place ( (i` -A- CtP-7—
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k
Date of Disposition-2 i(. Place of Disposition p;i( y, L JJ Gj c,44 c R\,L'
(address) Z
la
0
CC (section) (lot number) (grave number)
tt Name of Sexton or Person in Charge of Premises �A_i-' A. 4
(please print)
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Signature ce% j v �t%a Title
(over)
DOH-1555 (02/2004)