Dean, Gilmour NEW YORK STATE DEPARTMENT OF HEINIPIIIIF 4/ 771
Vital Records Section Burial - Transit Permit
Na First Middle Last Sex
LIIImI;«..r E 0e.cur1 Mole_
Date of Death Age If Veteran of U.S. Armed Forces,
11 - ) - 2-0((p I(n- War or Dates kit)Le ar
t- Place of Death Hospital, Institute n or
lu,,Cit. Town or Village C he j'�C( k/ Street Address La n tfrt ( ,i V i n ctt (eirrkr-
0 Manner of Death Natural Cause 0 Accident ElHomicide El Suicide ElUndetermiubd ❑Pending
ILI
Circumstances Investigation
tu Medical Certif Name Tit
r cJ-1 M U-4€- Pam'
Address
et
/
)pith Certificate File District Number Re ister Number
Cit Town or Village(jty ii(�c fci 0 I L , 11 coA
❑Burial Date met ry or Cre atory
['EntombmentI ' 3 I `(' 1 j�'1e V 1 e(A) `" ` rYu n/
Addres
]Cremation ,h;3*L 1- ( N
Date J (Place Removed
Z Removal and/or Held
2 ❑and/or
Address i;,,
Cl) Hold
Date Point of
;0 Transportation Shipment
G by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home 3-t -e r - r i y—cd �® yytt I I yV., 00
Address
c . -- Chlirt h St. Luck Lu2.ern, MI i2 o
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
IX
ILI
Permission is h reb granted to dispose of the human remains descri a
a ve a .nd. ated.
Date Issued H 1 2 201 Registrar of Vital Statistics
(signature
District Number LI LO v I Place 0_j
I certifythat the remains of the decedent identified above were disposed of in accordance with this permit on:
P
P ))(311b Dispositione?.L., Cw tt! Date of Disposition Place of � .—�
(address)
UI
Cl
CC (section) (lot numbe) (grave number)
CI Name of Sexton or Person in Charge of Premises � �"^a�
Z please print)
14 Signature a �" Title fl
(over)
DOH-1555 (02/2004)