Gohey, Marie NEW YDRK STATE DEPARTMENT DFHEALTH ��NN�~��0 ~ ���������~� D�^��8��^�
Vha| R000�oSm��n �~~~~ ~�~~ ^ ~ ~~~ ^~~~° Permit
Name First Midd
te
If Veteraii of i K- 6-d r6r6es.....
Date of Death Age
War or Dates
:z. Place of Death Hospital, Institution or
:Uj City,Town or Village Street Address
Natural Cause El Accid C1 Homicide D Suicide Ei Undeterm Zed Ei Pending
Circumstances Investigation
Medical Certif ier Name Title
Address
Death Certificate Filed District Number
Register Number
City,Town or Village
Bijrial
7
�R 01A A?/ -_______ __-�____
[�Cmm�o Address
-
~� ~~~...........
~_^ _~~~.
Date
PI ace
2 Removal and/or Held
�+ and/or Hold ---------------------------------'----------------
Cn
------Point of
------------------------------------
E]Transportation by Shipment
0� Common Carrier --------�------------------------------- ------
Destination
� - ------ ----------'------------
----'--
Address
� FlD���nnm� --- -Cemetery
-� -------------^ ........................................-- ...........-���e�.-������------------------------------
- Fl Roi�onnor� --- '
Permit Issued to Registration Number
Name of Funeral Firm
Address
11�' Name of Funeral Firm Making isposhion orto Whom
Remains are Shipped, If Other than Above
Address
d as no
s indicated.
Permission is hereby granted to dispose of the human remain ddoscri e abo
Date Issued 01 Registrar of Vital Statistics
District Number Place
� I certify that the d i accordancewhhdh�ponnhon:
/ i. ) /� L', DG �l C4-
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LLJ ���� � . v [v"eenummr8'
r—� (address) �u > /7 �
���| /«n / | r` �� ^7 ' / ^�-
(sectio ' umber) (grave number)
70.S
--
Name ofSex� Pe �Cha�e Premises ")�I/Z C- ( ToL
w�
�� (please print)
Signature f '~ Title Tc\57-Dy-
~_._--_
DOH'1555 (10/89) /z1of2 VS-61