Bickford, Gary NEW YORK STATE DEPARTMENT OF HEALTH P ( 13
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
&ley gt /31 cy ��;��L
Date of Death Age ,� If Veteran of U.S. Armed Forces__
l/Ace/l War or Dates V16 /N/+t'l
Place of Death Hospital, Institution or
A City or Village /tilt= V/GOI>l 8 Street Address j6, SA hll 7/2.-3 )..6-14
Manner of Death [4 Natural Cause Accident �Homicide _ Suicide Undetermined Pending
;U — Circumstances Investigation
Medical Certifier Name Title
t) 1�Ietitsl tS \«K- C,4 /10
Address
P d i3ax .76 l.Al: 60i,AC4 6 NL (1 19 `h/ ,
s Death Certificate Filed District Number Register Number
City, wn or Village h((;"We,iv\ /6-6 J ' 1 �j 3" 11
Date �ll Ce etery ort - ator
::: ❑Burial `1l/65/a.6// //N(L`r y t -IA(
Address
::.: Cremation Q u L L Af5 rru fay 1\t,
ZZ Date Place emoved
Removal and/or Held
and/or Address
F= Hold
t
.0 Date Point of
NTransportation Shipment
a by Common Destination
Carrier
Disinterment
: — Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to _ (I_Registration Number
1<si Name of Funeral Home �, iJ- (t )ziD 1, , J Kc y j L,dc,- ,A,1_ J }'"iC O�:5: c
'> Address /
-, '-M d20 a -S(C i'f 1, / . R`7G
Name of Funeral Firm Making Disposition or to Whom
ti Remains are Shipped, If Other than Above
Ole Address
34
Permission is hereb granted to dispose of the human remains describe eve� ---
as? indicated.
/°�
Date Issued 7 ),C/( Registrar of Vital Statistics J
at �,(.-%.�}c-
(signat e)
District Number /5 5 6) Place Ater L)C OM h N`y.
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
EDate of Disposition 4'12.'It Place of Disposition 'f:,.eOttu (r(,n.<tar)rA..
2 (address)
(/)
£E (section) / (lot num (grave number)
• Name of Sexton or P� son in Charge of PremisesCI (, r+1+ofhi,. „„11
(please print)
• Signature Title 02EOfToe_
(over)
DOH-1555 (9/98)