Gross, William NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First ` Middle Last �0�� Sex iiii
W \ ate
Date of Death s I Age If Veteran of U.S. Armed Forces,
�2� f I. 1- g 9 War or Dates
IN P - e of Death � t: Dit , Institution or �,A �Z �iV Town or Village CIe,'S TU IIS Address �l '�l S
ci anner of Death1Nalural Cause 0 Accident 0 Homicide ❑Suicide Undetermined ❑Pending
IM Circumstances Investigation
W Medical Certifier Name Title
Tbr . K./ 1e Lecno-ca V `A.
Address
\LID\ Ca-re 13 ,) CusmAz bwu.{ , IQ.-1 124
th Certificate Filed () S _red I s District Number Register Number Ce
Ci , Town or Village 7 I-&14 1-
Burial Date /2(/ Cemetery ormato
❑Entombment ' /- 19/ v �C/
Address /V�-J i lv 12d ULf
Cremation � �. Dual �� 1 /
Date Place Removed
t❑Removal and/or Held
2 and/or Address
l= Hold
0
o Date Point of
Si ❑Transportation Shipment
G by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home
Address
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
t
to
fl Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 7 /3 I ( ( 7 Registrar of Vital Statistics W C.A.N/p
(signature)
District Number 560/ Place G .CN.,S \\ "3/
�y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILfi Date of Disposition 7�.3///? Place of Disposition P,71 ;Cu)Q-v
a (address)
lid
Cl,
SC (section) (lot num er) (grave number)
ci Name of Sexton or i Charge of Premises .1 1,,<<..'0.-►. - a-.-ke
z (please print)
la
Signature -i Title e_re,e-4-
(over)
DOH-1555 (02/2004)