Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
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)