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Gray, Jody NEW YORK STATE DEPARTMENT OF HEALTH pp Vital Records Section ©Uri -Transit Permit Name Fir vb/ Middle A Last Le7 LE / Sfr Date of Death Age If Veteran of U.S. Armed Forces, 0 Y—�''S--to ((o -2..,, War or Dates --- ce of Death Hospital, Institution or /� ZOO own or VillailigeC., �f y,_ f' Street Address LI/ (Pova-t* i i'r g Q .anner of Death atural Cause ❑Accident ❑Homicide ❑Suicide El Undetermined' nding Circumstances Investigation W Medical Certifier me ,ni /Title v 0-rL�.V V vAPMy l�ORo,vEd•- Addre cam- WAVI p, e=?' r )/ i 4/ Death Certificate Filed District Numb Reg ber City, Town or Village �C o ' ❑Burial Date d,J— �i Cergl to orkemato r��l 4-72)12-S� [I Entombment `l �J� VI y� Address Reremation 2-1 CUik-leCFth R3,, CPv . .rtg Y NV i -2-P Li Date Place Removed' � ❑Removal and/or Held Address 0 Hold 0 Date Point of 135❑Transportation Shipment CS by Common Destination Carrier ❑Disinterment Date Cemetery Address ❑Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home le6LM�r�.-- 4...e.14.4./1 /077 Address 17 3 1Mr7,0 - , 4-10 . Ali LZ©/v/ Name of Funeral Firm Making bisposition or to Whom Remains are Shipped, If Other than Above Address II Q. Permission is hereby granted to dispose of the human mains described ove as in cat . Date Issued O '-2-P- ka Registrar of Vital Statistics , . / (signature) ilig District Number d f Place ✓�� •, ��� . I certify that the remains of the decedent identified above were disposed of in a ordance with this permit on: k Iii Date of Disposition t//11//(, Place of Disposition iLL_' 6144 4 (address) ILI Ir (section) (lot number) (grave number) 1411 Name of Sexton or Person in Charge of Premises (r,rt SQ 2. (please print) Signature 0 Title ! 'dui (over) DOH-1555 (02/2004)