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Gifford, Francis ► ti NEW YORK STATE DEPARTMENT OF HEALTH 27 14 Vital Records Section Burial - ransit Permit Name First Middle Last Sex FrGhC 1 V� �1 ��orC( M -iiii:iiii Date of Death Age I If Veteran of U.S. Armed Forces. ©`� 10\1 I IQ _CT I War or Dates /ci ao 1 g 59 44 Place o eath I Hospital, Institution or w City, on o Village Qveer\,S)oury I Street Address 12_PA;on �{,'v)e La r e y Manner of Death Natural Cause El Accident Q Homicide El Suicide n Undetermined El Pending { Circumstances Investigation xi Medical Certifier Name Title C3 C )\ F;\ u\'\ MVJ Address \"c-c''' C2r .12_*c G tk r► Rn\\s, tJ-'J i?-£to, 1 Deat -rtificate Filed I Dis ct N,mber Register Number City, ' own ► Village QJ��Sbv r� 1 S(.95 f U 4 Date Cemetery or Crematory ❑Burial O�I 1 \ ) ?l0) lD Pin-e. V i e vJ (,r e rha 7 Address " ::: g Cremation U UP_e r1�Sl'Jv r i 1 (Z�U .Nt • Date _ , lace Removed 8 Removal f and/or Held and/or Address Hold L__ 0 Date I Point of • N Q Transportation, C Shipment 5 by Common Destination • Carrier 9 Disinterment Date Cemetery Address n Reinterment 1 Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home _ f?iCtz- _;.,s y3-�,:Y- /iL Ii-, 0/1.50 " `*, Address / f_ i Et it L,)-- xg-= �-3-i-z,� S I j)o s as u r n r k . 12' y Name of Funeral F Making Disposition or to Whom I Remains are Shipped, If Other than Above `J Address - S. Permission is hereb granted to dispose of the human remains described^�ponve as indicated. m. Date Issued LE 1 l 1(A((p Registrar of Vital Statistics �� Q• CJ�f (si.nature) Place ' O fig District Numbe (Q�� d I certify that the remains of the decedent identified above were disposed of in act ordance with this permit on: r� Date of Disposition (111414, Place of Disposition Zµ ..•- �•--' 2 (address) ill I) II (section) //(�lot number) (grave number) 0 Name of Sexton or Person-in Charge of Premises • Lfhruf r S.L* 4 !/ (please print) �rrC Signature Title - (over) DOH-1555 (9/98)