Gagg, Ida I€L
NEW YORK STATE DEPARTMENT OF HEALI
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
6a_ciajPe.14ifik
Date of Death Age If Veterof U.S. Armed Forces,
8 — .8 — l1 -7 War or Dates AJ0
Place o Death Hospital, Institutio or /:
City, own r Village J D A.n.S b U Street Address AdL~ TC► G N• 14 •
Manner of Death
Natural Cause 0-Accident 0 Homicide �Suicide O Undetermin d 0 Pending
ILI Circumstances Investigation
LAI Medical Certifier Name itle
Thq.�-e J. 3 Q L. - .1 a�s •�IN
M prAddres `C
Ny
Death ertificate Filed District Number Register Number
tii City, own r Village J o ix n S b u, J`7
iiiiiiii ❑Burial Date etery or Crematory
$ —• tl —l-7 Ili n-cVIe,(A) 6-Crn0.71-9
im['Entombment Addri4s
r 'Cremation l Q r sbu Date lace Removed
❑Removal and/or Held
F
aHoldor Address
= nd/
CO
0 Date Point of
ti ['Transportation Shipment
C by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M t 1 I( hL&.Q r cul - j yy,t_e__, O l l i e,
Address
te 367 MI 5 3 a I nd i ayi taAJL Ni/ I z8 L/
Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
'„ Address
tr.
to
'` Permission is hereby granted to dispose of the human remains de crib abov s indicated.
Date Issued `3istrar of Vital Statistics 'l
I Cli "j (s nature) 6/42.__0,A)
District Number 5'(o 5'5 Place ( vwn o fJv iV
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
III• Date of Disposition QiNlii Place of Disposition 4,A).-,. ,y,Jir,.
(addre s)
ILI
to
fr (section) 44+1t1
(lot number) (grave number)
Name of Sexton or Person in Charge of P mises n Sii4II
( ease print)
) Signature Title I1 fM
(over)
DOH-1555 (02/2004)