Gusten, Dennis 414 ft 315
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
N e First • Mi le Last Sex
Date of Death Age If Veteran of U.S. Armed Forces,
Ei l 1 \l (p 5 War or Dates 1%1
Place of Death g ` Hospital, Institution n �� 4
Ci , Town or Villa e '� u 4 Street Address tA) k
Manner of Death Natural Caus4Q A ciden 0 Homicide 0 Suicide Undetermined 0 Pending
Circumstances Investigation
ili Medical Certifier I) Name Title
14 kith l I n"t J
Address �a��
l31 2Zt -- -(.. ,4 n--�,��l c
Death Certificate Filed District Numb, r II U Regl�ter Number
Cit Town or Village �s. _" .--,..,:i,,,,,,
<: OBurial Date 6 i ete y or Crem ry
❑Entombment 0 1 9/t2-0'1 V f12.- (:.—A- .ti`K Q-�
Addre
Cremation (�.k-L-7L 1zic;u..1 `�
Date ace Removed •
Z Removal and/or Held
❑and/or
H Address
IA
Hold
0 Date Point of
�❑0 Transportation Shipment
t1
caby Common Destination .
Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
•
Permit Issued to Registration Number
Name of Funeral Home `'1-C--uLCA 4Lk� -24-. (;CADS
Address 0 ,
Name of Funeral Firm Making Disposition or to Whom j
Remains are Shipped, If Other than Above
2 Address
tr
ifs
Permission is her by ranted to dispose of the human remains d ibed above as indicated.
Date Issued ( ) 1 Registrar of Vital Statistics 4—Q.NN 'P vevt.t.ik
(signature)
District Number Place SARATOGA SPRINGS
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
i
Z
til Date of Disposition t./Zo I II Place of Disposition i„u tJ Creb,.e{cif t„‘._
2 (address)
W
it
i (section) (lot numbe • (grave number)
di Name of Sexton or Person in Charge f Premises t�ir.1.111114f. „He A-
Z //1t i (please print)
Signature41 1 7i Title (9 AAA
(over)
DOH-1555 (02/2004) •