Gray, Thomas . -,.. li -71g)
NEW YORK STATE DEPARTMENT OF HEALTH :.i'-.' '_,,,Ni;':; ;r-
Vital Records Section Burial Transit Permit
pi, Name First71,- Middle Last Sex.---,
11 t OAS . ,.
i Date ot Death - _ .. „ A e If Veteran_of U.S_.Armed Forc ,
.O 3 , 01 b a . a , War orf Dates
iiP• lace of Dea • Hospital,Institution or -
City,Town •r illage .p,r`.; ._ .,. Street Address 16 1l o,t _AVM
Manner of i3 Natural Cause Accident°-Ej Homicide Q Suicide ri Undetermined ri Pending
. , , . • • Circumstances Investigation_
la Medical Certifier Nam
° title
fl =:.. , &ear+ c s 4;4.
.D
` 3 Address •
41�,� �, (of`
J I-..a__J 3
Death Certificate Filed ,-, ,-' District Number - Register Number
k,:
::hh City,Town or Village - —, - ;-_ ., �'
r ,Date Cemetery or Cremat
❑Burial'~ /0/`3 a of 6, ,1 c.✓.c Li r e, . ,
Address , •• . -,
P t Cremationee_A `'"7. .
Date ( • Place Removed -- '
ri Removal and/or Held
and/or Address
Hold
0 Date Point of
N0 Transportation Shipment
fl by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address •
gi Permit Issued to Registration Nu er
:g< Name of Funeral Horr -
c'n<,n,,nrc ,N�L r t -1."-t� 2 c` `y"
Address
Liii N• ame of Funeral Firm Making Disposition or to Whom
#. R• emains are Shipped, If Other than Above
=4 Address
au
Permission is hereby granted to dispose of the huma• emain- describ-d a• •ve as indicated.
Si~: Date Issued 1 Registrar of Vital Statis ics �1
(Si. ure)
Si District Number ItS Place JvZ2�,
?; I certify that the remains of the decedent identified above a disposed of in accordance with this permit on:
6 Date of Disposition /b/J tit, Place of Disposition e Jtt. tr►matt-ec.✓
2 . (address)
N
CC (section) (lot number) (grave number)
0 Name of Sexton or Person in Charge of Premises G�riS .P' 3441r '(please print)
t. Signature t 1 Title (1 ►1tildr
DOH-1555 (10/89) p. 1 of 2