Hart, Gail l J /
NEW YORK STATE DEPAR MEN] OF HEALTH
Vital Records Section Burial vial _ Transit Permit
`i Name First Middle ,o-t I Sex
>, -, flaI LLrA r /t.4 I r5/1/1 t,rl'
Date of Death / ( Age ± If Veteran of U.S.Armed Farces,J
/ b/q/i 7 1 1,,s I War or Dates W g-
Place of Death 1 Cospirt Institution or
M Town or Village aL u�s rgz,w ( Street Address C e-', s Fin Ix
In Manner of Death Natural Cause [l Accident ❑Homicide n Suicide 0 Undetermined ❑Pending
r
Circumstances Investigation
j Medical Certifier Name Title
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Address y
to t7t ii-f r-S tJ�►y o?i1 A S � /Q LN 1 U df
Death Certificate Filed 1
District Number 6 I Register Number
: Cit% Town or Village G+ --,u s Flivi,i- i
" ` Burial l Date Cemetery ocCremato 1
❑Entombment J old /17 �,,.yt` t'i J
Address
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Cremaaon Q v D-9t b-v.- Q u i)S e Oal
j Date j Place Removed
kn Removal I I and�,or Held
and/or
j Address
— Hold {
ri
ek
Date Point of
Transportation Shipment
by Common Destination
Carrier
❑Disinterment Date ! Cemetery Address
_ 'I n Reinterment Date Cemetery Address
I
-« Permit issued to ( Registration Number
Name of Funeral Home l,...tc� :,-\L,--cm \-1C f�� -�
:: Address C' t 1 .�0
:: Name of Funeral Firm Making Disposition or to Whom -
Remains are Shipped, If Other than Above
M Address
Permission is hereby granted to dispose of the human remains described above as)ndicated.
Date Issued I U l i t /2() j ' Registrar of Vital Statistics 6/JW
l C°� U (signature)
I District Number 5 601 Place / �N`S \ \ S iv
Sdi
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ill Date of Disposition Ma Place of Disposition f 77,1mc trry.....`
(address)
(secion) (Mt number (grave number)
Apart
fal Name of Sexton or Person in Charge o"Premises ! �•}� C'''`��
i J fp!At-
prints
Signature tt- Title fktft .-
(over)
DOH-1555 (02/2004)