Gregg, John NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial Transit Permit
..
giii Name First f p Middy Last .gte_g
Se � �
i Date of Death // / c Age 2lf Veteran of U.S. Arme Forces,
I 9 /.- - War or Dates / V/g 7.5-
Place of Death / Hospital, Institution or
City, Town or Village" • ,lie Street Address
Manner of Death1
uj Q Natural Cause III Ac lident 0 Homicide El Suicide Undetermined Pending
/� �
Circumstances Investigation
Medical Certifier Name Title zi,(1
Address / - -
s'' Death Certificate Filed G ��� �� D tric��er' / U Register Number
in City, Town or Village 412-4112.-, l g
I�I Dat Cemet, or Crematory
El Burial / i� �- !/ )_�_er �
Address
Cremation (63
Date `+� dlace Remo
❑Removallej and/or Held
and/orliTi Address
g. Hold
Date Point of
Q Transportation Shipment
5 by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to ( Registration Number
ii:ii:: Name of Funeral Home �ie.6/ �-L J �e-.e.. t-�' 2'4-x, D6.2 6 7
im
iim Address /7 - ik4f--eA-V r_- *.e.,...,—.7,7_, --72/7y.
Name of Funeral Firm Making Disposition or t6 Whom
Remains are Shipped, If Other than Above
I
Address
al4NO Permission is hereby granted to dispose of the human main sccrriibbeed a e'=s indicated.
ill �'� � �, j Date Issued /-/d -fl Registrar of Vital Statistics >j� 7,1"*-4
• t re)
District Number , , Place {
::> I certify that the remains of the decedent identified above wer disposed of in accordance with this permit on:
.1
WDate of Disposition 1/1 2/96Place of Disposition p. Tip vi PW ePmatPry, OiiePnsbivey, NY
2 (address)
ILI
CD Mohican 87-E 1
Et (section) (lot number) (grave number)
GName of Sexton or Person in Charge of Premises MichaelLopez , Working Foreman
Z (please print) 1
iE! Signature Ridlie Title LP,Ce ��
DOH-1555 (10/89) p. 1 of 2 VS-61