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Gilbert, Dorothy NEW YORK STATE DEPARTMENT OF HEALTH J 3 Cr Vital Records Section Burial - Transit Permit Name first Middle Last ex 411, r Date of Death Age If Veteran of U.S. Armed Forces, "'3 3 -c -D—D Le -7c '- War or Dates --, t:... Place of Death Hospital, Institution or P.Ct. City, r Village �} _ Street Address 7 ! 1 4kc� L b' A Manner of Death 47 Natural C se 0 Accident 0 Homicide 0 Suicide �Undetermined J Pending Circumstances Investigation fli Medical Certifier Name . .5 .. Title \Addre •••• ' Death Certificate File District Number Regis r Number T 0 City owI or Village (,\,i. c g Date 1 � C tery gr Lak iatcy } :::: ❑Burial ( (/� ( Y` Addre rrn >. ®Cremation b_ iuTg Date"` "��� P e Removed 0❑Removal and/or Held ••• and/or Address lg Hold 0 Date Point of N Q Transportation Shipment a by Common Destination Carrier :.:-: Disinterment Date Cemetery Address Reinterment Date Cemetery Address E. Permit Issued to Registration Number ?< Name of Funeral Home y,) - ZACLk 0, -C. O i f >' Address Li Oh 1,111,.01_. Yyl---),e,/viut )t ( ' /dName of Funeral Firm.Making Disposition or to hom m" Remains are Shipped, If Other than Above Address I M Permission is h reb granted to dispose of the human re +'�-'1 ns descr' d abo icated. ni Date Issued O_ ©ZO Registrar of Vital Statistics .i I j (signat e) Mil' District Number t2 Place-rC i.,U7`l `� � I certify that the remains of the decedent identified above weretsposed of in accordance with this permit on: E. Date of Disposition 1- Disposition / i W! loll='4J �1Z-� t V 1a i`v efi p 3� �� Place of M (address) a, (sAction) (lot number), (grave number) GName of Sexton or Person in Charge of Premises t1-1Z-`f la, I -&I -1--- g (please print) t U Signature Title C,a c b (over) DOH-1555 (9/98)