Gregory, Glen ,� 4t ZZ7
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section 't Burial - Transit Permit
Name First Mid le Last Sex
G*/ .v 47/ C arty- 17
Date of Death Age If Veteran of U.S. Armed Forces,
QS-0//24.1// 2 F. War or Dates 7/`7�—� J�3
Place of Death Hospital, Institution or / AG‘ 7 4/
City, Town or Village 6le�s AA Street Address �j �
0 Manner of Death NJ. Natural Cause Accident Homicide 0 Suicide Undetermined Pending
ilk Circumstances Investigation
LAI Medical Certifier Name Title
4 iee/l. ��/1. , v- a 3/729
Address
joc k skzeil o/- Al/. ti>:
Death Certificate Filed District Number Register Number
sC City Town or Village (s�/v' / V �/ —
❑Burial Date Cemetery or Crematory
ni❑Entombment OS%U 3/2.o// /�iJr U/�yl, �/1-292/l�it�
Address /
Cremation 6 i..�.S�JU/t>i N9 /;t(:7
Date Place Removed
Removal and/or Held
ita Hnd/oldor Address
to
0 Date Point of
Q Transportation Shipment
G by Common Destination
Carrier
❑Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
iii Permit Issued to //11�� )41 5!/ // N m RegistratiiNumber
iiiiii Name of Funeral Home /��/'f ii.�i p/ �.. � ,1
Address LA-- -, .
'�r
// G./�"//-,. , --“e,/ QJe e, stz.-Yt y, ,('y/ c)
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
;';r Address
CC
Ili
Permission is hereby granted to dispose of the human remains e�scribd ov i dicated.
Date Issued os2/4// Registrar of Vital Statistics ii�e-rl� 4
9
(signature)
District Number ,5 j/ Place ./&,„Q /^/ /(-
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
lit Date of Disposition S-i-i t Place of Disposition -P+►c 11;xv C. {e r ay...,
(address)
ui
to
ric (section) (lot ny''�ber) (grave number)
0 /i-
ilk Name of Sexton or Person in Charge Premises L 1•1-1 Jp r(1-
" /,l (please print)
10 Signature l "► C `
9 Title iANda-
(over)
DOH-1555 (02/2004)