Gordon, Marjorie NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Mid Ie L st Sex
, t.-r/6rice, C.,e /i er Or-do 0
Date of Death i'l Age If Veteran of U.S. Armed Forces,
0 9 -b ie, 9� War or Dates
Place ath 1` Hospital, Institution or r
Ci Town Village 1 L ) � f Street Address •�4.`� 1-to /`t Lt Y51 A-j T16 .,
Manner of Death Natural Cause D Accident D Homicide D Suicide D Undetermined Pending
41 Circumstances Investigation
tu Medical Certifier Name Title
_Su
Address 2 J
Death icate Filed `'�District Numb Ref- 'NI j7tS r
Cit}(Town r Village ) %AO
il DBurial Date 9/0,70 / (e Cemetery of.-Crematory. rx // (Li
DEntombment Address / �
8remation C2 t/ As S b tL fr"i;,j N y
Date Place Removed
", ElRemoval and/or Held
and/or Address
C= Hold
8 Date Point of
la El Transportation Shipment
d by Common Destination
Carrier
El Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
0 Permit Issued to � /� Registration N tuber
Name of Funeral Home 0 a--r /`e TU i 1—t-t L rcL hc.e 1-" e 06 ('?S /
Address f 6 , e_i IL S' 4cat_ci o i 1 o 5 N / ,D- - 3
Name of Funeral Firm Making Disposition or to Whom
ti Remains are Shipped, If Other than Above
'' Address
C
lit
9,' Permission is he eby gsanted to dispose of the human remains escribed above
�asindicated.
Date Issued �',0`1! /0 Registrar of Vital Statistics'f z ��►� �" ( ��
(signature) (i
District Number c Place ) plc) r) 0-r xx_L_J G ,titu
/���JJJ
,,,,,,,,,„,
,....::.„,„„, I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
la Date of Disposition LI OM, Place of Disposition /jijiiwcn
(address)
i
CC (section) w (lot number) (grave number)
Name of Sexton or Person in Charge of Premises a0-4r .Si4drt1
(p ase print)
114
Signature jj— Title ea
(over)
DOH-1555 (02/2004)