Gunn, Mary NEW YORK STATE DEPARTMENT OF HEALTI4 '
Vital Records Section Burial - Transit Permit
Name First Mid le Last Sex
Date of Death Age If Veteran of U.S. Armed Force
Cy-a/- 9-e/17 6 '( War or Dates
i--, Place of Death `-�'' Hospital, Institution or
ZCity, Town or Village Td4ws 1u Street Address Mir°AAa��'Tri aNegJI4&aFo Cam,.
is Manner of Death Natural Cause Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
W Circumstances Investigation
W Medical Certifier .Nne Title
O k A ices /4/Nccso� 1
Address
/la SA de0i A po 0 1--, 1, eyez-e ,�x / .5"3
Death Certificate Filed --�— District Number l Registef N, imber
City, Town or Village }Jot ) k�r•g .56,,� o�d
❑Burial Date/ [ CerNtery or Crematory
❑Entombment ` G ` 9,3 l'7 '1 /Ai e 0 i e w Cal -r-1l►Til -i
Address
E Cremation (-9) Veit;s 3 u ry A.1�' '
Date Place Removed
Z❑Removal and/or Held
Pand/or Address
Hold
0 Date Point of
ti❑Transportation Shipment
0 by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to � Registration Number
Name of F eral ome c LA 1.- <4,--t/y / ONprA( N pose_ C-rf.si
Address
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
$ Address
Ul
Permission is hereby granted to dispose of the huma emain des red • - - indic_54111
Date Issued fir Ia3/ 20 / 9 Registrar of Vital Statistic .` ial � '
i
(signature)
District Number Place-- tQ �` �.1 !n b Lir
I certify that the remains of the decedent identified above were disposed of in accordance with this'L-' it on:
2 p
ti Date of Disposition Phil l l Place of Disposition f intU--- C.+r,c40�
2 (address)
w
VI
(section) (lot number) (grave number)
n Name of Sexton or Person in Charge of Pr ises ��^+ ,�o, `�r
2 (pie a print)
• Signature a Title Io1i�,_
(over)
DOH-1555 (02/2004)