Carlton, Gloria • , li # 50
NEW YORK STATE DEPARTMENT OF HEALTH _
Vital Records Section Burial.- Transi Permit
Name First/' - --Middle / L st Sex
(PLor:G.. .�, , C-,4-rL& , t'
Date of.Death Age If Veteran of U.S. Armed Forces,
77i s— 7z0ia 70 War or Dates -
- i4 Pla of Death r Hospital, Institution or /�
own or Village C�91�T� Street Address Co c -,
q Manner of Death Natural Cause El Accident [l Homicide' Ei Suicide �Undetermined C Pending
Circumstances Investigation
111 Medical Certifier Name Title
II c4 (na-". 1e1wz-ill; Mit--
Addr4s '
G r H>> . i.� 100 �4,t/ st 6 L - -..i27 7 I Asa 1
r-_ CertifiPate Filed �-- District Nur?iber Register Number
own or Village 6.10 5-6 a (
❑Burial Date . • d 1 Cemetery or Crematory • '
7` O1 ,./(0 ,/leWC.w �.r-1.40C)
❑Entombment Address
v
ii [ Cremation .ate ASS r �c� /a/� '
Date • ) ? Place Removed
Za Removal and/or Held
and/or Address
t" Hold
O Date Point of
iii Q Transportation . Shipment
®. by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to ---- r — Registration Number
• Name of Funeral Ho -n5.4t9rc- /,,4.,ner4L 41.^-� .L --- • e2b`t`4l
Address -7----7 3 r �_
c�r� G 1r. . ) a�
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
. 2 Address
g
• Permission is here y ranted to dispose of the human remains descri d above/its in ' ed.
>'. Date Issued 7 16 � 1v Registrar of Vital Statistics / L -
(signature)
District Number '6,0/ Place ?La,1 -- - I i, ) /t � 1
•
•>. I certify that the remains of the decedent identified above were disposed of in
accordance with this permit on:
l Date of Disposition -711I((b Place of Disposition 40,..... am+
2 (address)
LU
0
,:., (section) number, (grave number)
a Name of Sexton or Person in Cha ge of Premises 1.,(lot
s
(p ase print)
Signature a Title C rnl'C
(over)
DOH-1555 (02/2004)