Gonyea, Armond 0. 1
# 56
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit P rmit
Name First Middle Last J Sex
krrncind P. Gonl riot._ I M
Date of Death `� ( Age 1 If Veteran of U.S. Armed Force ,
t! ?_O1 l J 1 g War or Dates AYi-
• Place • •-ath Hospital, Institution or p
Cit , Town •r Village s treetAddre wZ i c r• 1-CX)-C`
Man - of Death]' Natural Cause Accident Homicide 0 Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
�N D>2�� Al
Address /11� �' /J l !i evWU S o-J if er L a'AJ 1 ! ira-_S / " / 07
Deat tificate Filed Distri a Register tuber
IIIIIIII g
,b____
CityClowjA4r Villageo 2 6 -%)
Date Cemetery or Crematory
E Burial O$'S--j o201 to Tone e \ L e to C& maw r�/
Address /
II:II ®Cremation Q U filL8Yk__ Q Q UGC ltlr
Date I Place Removed
O❑Removal I and/or Held
�'
Q and/or Address
Hold
Ff)
Qet: Date Point of
(73 Q Transportation Shipment
5 by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
kik Permit Issued to J/ Registration Number
IIIM Name of Funeral Home — i}C�;Z2 F�,Ln,;• ANt 0/139
' Address
l/ 1- �Trz' S; Q u ,os 6 u n� /U , l i
Name of Funeral F Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human rem ' describ a• •ye as indicated.
9 /itii d
Date Issued / ��� Registrar of Vital Statistics p /
(signatur)
District Number qs--&D___ Place�j� �l nc,k-S /67d J` � � / ) J�127
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition !ill hi. Place of Disposition g•tU1k/
2 (address)
LU •
(/)
C (section) , o nu 11mler) (grave number)
O Name of Sexton or Person in Charge of Premises c�i Lb
Z (please print)
W Signature A ib., Title akM'lilia-
(over)
DOH-1555 (9/98) -