Gozza, Frank PERMIT MUST ACCOMPANY REMAINS TO DESTINATION
FORM BT-1,12/2010
STATE OF NEW HAMPSHIRE 1.BURIAL PERMIT NO
BURIAL TRANSIT PERMIT 2.CITY OR TOWN
3.DECEDENT'S NAME(First,Middle,Last) 4.SEX 5.DATE OF DEATH(Month,Day,Year)
FRANK PETER GOZZA MALE DECEMBER 7,2014
6.AGE 7.DATE OF BIRTH(Month,Day,Year) 8.CITY,TOWN,OR LOCATION OF DEATH 9.COUNTY OF DEATH
64 Years SEPTEMBER 16,1950 DERRY ROCKINGHAM
10.METHOD OF DISPOSITION(1.Burial 2.Temp.Entombment 3.Cremation 4.Donation 5.Mausoleum 6.Other): CODE: 1
11.PLACE OF DISPOSITION(Name of cemetery,crematory or other place) PINE VIEW CEMETERY
12.LOCATION (City/Town,State) QUEENSBURY,NY
13.DATE OF DISPOSITION(Refer to 19a) DECEMBER 11,2014
14.IF ENTOMBED(OR CREMATED)PLACE OF FINAL BURIAL
15.LOCATION OF FIttIAL DISPOSITION(City/Town,State)
r ; Alt I ev6'471-
A CERTIFICATE OF DEATH,HAVING BEEN FILED AS REQUIRED BY THE LAWS OF MS STATE,PERMISSION IS HEREBY GIVEN TO:
16.FUNERAL DIRECTOR ALICIA M FORD 117.N.H.LIC.NUM ONLY 1023
18.NAME AND LOCATION OF FACILITY(City/Town,State) CAIN AND JANOSZ FUNERAL HOME,MANCHESTER,NH
19.COUNTER SIGNED AGENT(City Board of Heath/Sub-Register if app.) 20.CITY/TOWN 21.DATE ISSUED(Month,Day,Year)
ALICIA M FORD DERRY DECEMBER 9,2014
CEMETERY OR STORAGE VAULT AUTHORITY SHALL FILL OUT SPACE BELOW WHEN APPLICABLE
22.IF STORED,BODY WAS PLACED IN(Name of Storage Vault) 23.DATE STORED(Month,Day,Year) 24.CITY/TOWN,STATE
25.SIGNATURE OF SEXTON OR PERSON IN CHARGE OF STORAGE VAULT 26.DATE ISSUED(Month,Day,Year)
CEMETERYOR CREMATORY AUTHORITY SHALL FILL OUT SPACE BELOW
27.TYPE OF DISPOSITION(Cremated,buried,etc.) 28.DATE OF DISPOSITION 29.NAME AND LOCATION OF CEMETERY OR VAULT
(Month,Day,Year) (City/Town,State)
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30.SECTION 31.GRAVE NO. 32.SIG)ATURE OF SEXTON OR PERSON IN CHARGE
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This permit,after being signed by the Sexton or person in charge(or by the Funeral Director whe ere is no Sexton)mustbe forwarded within six days to
the clerk of the town in which the disposition takes place.