Moon, Gladys 413
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sexes
GI4c) s Loci /'1oO41
Date of Death Age If Veteran of U.S. Armed Forces,
12 3i 2.01/ 92 s War or Dates /t/ A.
.1. Place eath Hospital, Institution o??''
City Town or Village khi,KIIIAirwsbu Street Address
• Mann r o Death Natural Cause Accident 0 Homicide 0 Suicide Undetermined Pending
1 Circumstances Investigation
til Medical Certifier Name Title
TAOrms t J7"ar 2 /41J
Address
...... Citifigi42e1 Ou eirt.1 ve ii...po ,„
.....
......
.....
Death -e ificate Filed District Number Register Number
City, own or Village (IJArar/r i� sere Z 3
;, ❑Burial Date Cemetery or Crematory
['Entombment 379iv 3 , -- t�14 10 12 1,4✓ d g r99ye47
Address •
';:;Cremation _ QllEf.',1/Siur2y, A - /ZSitO"
Date Place Removed'
Removal and/or Held
and/or Address
�=` Hold
414 Date Point of
Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
QReinterment Date Cemetery Address
•
Permit Issued to � Registration Number
Vi! Name of Funeral Home M AIA/ �-f t7A/', /J4,ip - Sa c
ni Address
1 I LedniferrC Sr G tif. s 6Qn, ,v, ,2C-49 V
I Name of Funeral Firm Making Disposition or o Whom
Remains are Shipped, If Other than Above I4 di;)61,Apt z�l/rr,,,rta
;; Address
IX
is
't Permission is hereby granted to dispose of the huma• describ d above as indicated.
ii•iiilDate Issued 1 -3-- 1 Z Registrar of Vital Stat: // ' yc�.. ,,{�. ��./
( Y
(signature)
iiiil District Number 56‘0 Place l/h IA
"lig2t, iy K'A/4 / 14/1/2-4 �` .fr' / S
1.II certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
111• Date of Disposition 1-LI-it Place of Disposition eN4u4s -rtrwc tut iv„--
(address)
tli
iGf;1:
CC (section) (lot number) (grave number)
a (1r S
a Name of Sexton or Per n in Charg of Premises *'} �t(please print) �.1.4(1-
jli L Signature kl�'4--- Title CC�E p 4ei
VVV (over)
DOH-1555 (02/2004)