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Gagg, Edward NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section i. Burial - Transit Permit Name.... First Middle Last Sex 6600_ 0a /e. Date of Death Age If Ve of U.S. Armed Forces, (4 —3--/Co 85 War or Dates lore a }- Place o Death Hospital, Institute n 9r iii City, to r Village jO h n 5 lock Street Address K I f',wer term/Ours in >?La4 p Manner of Death❑Natural Cause ❑A dent ❑Homicide 0 Suicide ❑Undeined 0 P nding IiiCircumstances Investigation tit Medical Certifier Name Title 0 Address , Death ertificate Filed District Numbs Register Number City, •r e orVillagesJ0�nc bu rq�/ '�- l a( ❑Burial Date / mete y or Cre atory ❑Entombment ©eP ! 0 / J 2OI40 Ile. V1 Pv) CI'P.YYI��!'l Ad Ass Cremation ns2, 3i Date Place Removed Z❑Removal and/or Held and/or Address to Hold O Date Point of t` Transportation Shipment G by Common Destination ei Carrier 1-1 Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M I 1 lef -t erle- rk 1-0me.. 0109 99 Address (o 5 1 8-tClk ! tt 3o t rdiQ/i Lake/ AA/ l? 7 Name of Funeral Firm Making Disposition or to Whom } 1 Remains are Shipped, If Other than Above Address IX tt 07: Permission is hereby granted to dispose of the human s des ' ove as indica Date Issued 6. �- 1 to Registrar of Vital Statisticse.9, ure) District Number Place - 01-v\q( t! ., . :. I certify that the remains of the decedent identified above were disposed of in accordance •th is permit on: k tI Date of Disposition 6 I ic fit, Place of Disposition 40,....) (�,r►ofo,-..., W (address) to CC (section) (lot number) (grave number) Name of Sexton or Person in Charge of Premises As J z ( ease print) la Signature Cam( Title ��64'DC (over) DOH-1555 (02/2004)