Hayes Jr., Gordon NEW YOi?;K STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Date of Dea Age—I If Veteran of U.S. Armed Forces,
& /`y" / 2 War or Dates A4
J- Place of Death Hospital, Institution o�,-- ii
City, owr]or Village 1 4�Jv/- Street Address fV�f molitca4 f46-"i�7 #1�0
aManner of Death Natural Cause ❑Accident ❑Homicide ❑Suicide Undetermined Fending
i J Circumstances Investigation
tii Medical Certifier Name � le �Tie _.
Address47 / >
/1/4//4'7(211
Death Certificate Filed District//t/ ,if; .,1/Dumber Regi ter Number
<< City, . •r Village N,,A,. em
B i �'5 c
Ur al Date r etery or Crema�ftorry P J /,
❑Entombment ��" _ � / ig`''6/ V; I am'L "A I C:14f
Address /�
Cremation b? ,_ -i eo .^� z,�2. 4
L
Date Place Removed
❑Removal and/or Held
and/or Address
~ Hold
0 Date Point of
Di0 Transportation Shipment
E' by Common Destination
Mi Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
»: Permit Issued to /� Registration Number
Name of Funeral Home✓ 7'i ‘ Z , 1ct kLV' 011/. 0
s : Address// /, r'- 0 a/f/j{° / �o'f
iiiiiili Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
t:L
a` Permission is h eb granted to dispose of the huma ains described abov as indicat d.
Date Issued Registrar of Vital Statis . s i
,0346,
(signature
District Number% Placee- A___—.---
I certify that the remains of the decedent identifie ove were disposed of in accordance with this permit on:
z
tU Date of Disposition 4/1 8/1 2 Place of Disposition Pine View Cemetery
2 (address)
1E[
coSingle Tnterment Sec_ 2 95 1
CC (section) (lot number) (grave number)
CI Name of Sexton or Person . harge of Premises Michael Genier
z _ (please print)
4
Signature) ..9• N" Title Superintendent
(over)
DOH-1555 (02/2004)