Gauvin, Gordon t
0 3g
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial Q Transit Permit
Name First A Middle tC 61-Lik) frj I Se
f,:i§1 Date of Death I I Age / i If Veteran of U.S. Armed Force
1 i 9 /? 1 q I I or Dates Afi
E e of Death Hospital nstitution o
2 4/0own or Village L�,-) P-Oliiej I reet Address Ll .JS �'
anner of Death N Natural Cause 0 Accident El Homicide D Suicide �Undetermined 1-1 Pending
LtI Circumstances investigation
-
It Medical Certifier Name Title '�
0 W 1 CA,I t7 erd 1. V -J b"- / U
Address
i 00 ( U7U C . C Lis,s3 F v i -/u i 2L'O/
Death Certificate Filed i District Number R ister Number
•Town or Village L If/US Fits I 0 I �� _
■Burial 1 Date l / )1 I
/ 7 Cemetery or remato
:;„:„,,En tombment )"� V:41/61J-
-:::
Address /Jf� rema#ion l�G Ue'/��`, Yd 0 t}�/L1S(�' Date j Place Removed `
a C Removal ( and/or Held
and/or Address
F
Hold
0 Date Point of
tt— Transportation Shipment
by Common 1 Destination
Carrier 1
s > Disinterment Date Cemetery Address
Reinterment I Date Cemetery Address
Permit Issued to 1Registration Number
Name of Funeral Home '& E_ ��;\e_,ZIA t-!Oc c\k- III C,•t l C'
Address it j \ , 1 , KIN 1-2-
Name of Funeral Firm Making Disposition or to Whom
4 Remains are Shipped, If Other than Above
Address
III
rL
Permission is hereby granted to dispose of the human remains descr b d ov as i ted.
Date Issued 6d fl/ZC�/ Registrar of Vital Statistics i 'L'
(signature)
District Number 5—ay Place �� A` /U;/
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
UIDate of Disposition 1/131►j Place of Disposition 'CintUkv.+ C`°n gt"orm
(address)
1I
i
Cr, (section) (lot number (grave number)
CI Name of Sexton or Person in Charge of Premises `lr'fi St.-AA!II
7
please print)
44
Signature �/( Title CF6-MfCRA-
(over)
DOH-1555 (02/2004)