Gelinas, Iona P 1
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First , Cl Middle Last Sex
c LIir1R3 r
Date of Death + Age If Veteran of U.S. Armed Forces,
Ot 11(0 ' 2O\ko I �p War or Dates
1== Place of Death Hospital, Institution or
W �`City, Town or Village We�n�� Street Address
W' Manner of DeathLsj Natural Cause E Accident 0 Homicide ❑Suicide Undetermined D Pending
Circumstances Investigation
W Medical Certifier Name Li, , i Title
Ii Address el n ` , Z .Z Z
II Death Certificate Filed � District Number Li �S Register
City(f own -Village �`
❑Burial Date Cemetery or Crematory
O1 \VA \ Zo 1(0 9 e Ve�? CceM4.-or
❑
Entombment Address
®Cremation 2\ Q c ta\ of (Loci Dc t2 e cnS n� )Ul 1 2BD
Date Place Removed J
Removal and/or Held
0 and/or Address
HHold
M.
0 Date Point of
CIL
to Q Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Q Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home 02C 3iY 1c,cf.__ rurlej•c--Q ' ' l e_ 0 tiff n
Address n
Name of Funeral Firm Making Disposition or to Whom
114= Remains are Shipped, If Other than Above
2 Address
LC
a Permission is hereby granted to dispose of the human ain descri ab indicated.
1
Date Issued D/,.l r Registrar of Vital Statistics
A (signature)
District Number • /-__53'3Placefii Cer17 -141 7
I certify that the remains of the decedent identified above were dis sed of in accordance with this permit on:
W Date of Disposition I /70//1. Place of Disposition 47ru U (w lD(L^-
5 (address)
W
(I)
re (section) — /// (lot nupber) (grave number)
0 Name of Sexton or Person in Charge f Premises l/X',f '^
Z f (please print)
Ill Signature �L Title <ip-r"f�L (over)
DOH-1555 (02/2004)