Berry, GaryLee NEW YORK STATE DEPARTMENT OF HEALTH('
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
b-CUv lee- Ze r( M
Date of Death Age If Veteran of U.S. Armed Forces,
Cik )2j \2C3\lD 5 5 War or Dates IQ \\A
14 Place of Death Hospital, Institution or ii rr
y, � � �Town or Village �- '\\g Street Address -t 5 Lot Rose. S4-
ta Manner of Death Natural Cause 0 Accident Homicide ❑Suicide Undetermined n Pending
tlf Circumstances Investigation
W Medical Certifier Name Title
f4 C V\r i S --09rJ2 v' a- -' \-\ '
Address
1 CO CP.ir-e (Q ja ra ,) �sir3vr I Liz V
Death Certificate Filed District Number Reter Nurrtber , /
Q Town or Village �\e�n.s F\t.� 1 .504
IF❑Burial Date(Vd 2-g I 20\LP Cerrptery or Crematory
0Entombment Address /
'< _0Cremation () 1C'x\CAA/ c)—e‘- S ,4' I /...)NI 1 Z$'0?
Date Place Removed j
.Z Removal and/or Held
❑and/or
N Address
to Hold
L? Date Point of
Transportation Shipment
Q by Common Destination
Carrier
Q Disinterment Date Cemetery Address
ii:R"l '0 Reinterment ill Date Cemetery Address
iiiii Permit Issued to Registration Number
Name of Funeral Home N-y r \Z.;Ne.c-r \ \-ND cn t C'`t 1 L
Address ,,
1'% LoSay e. . ►-- C cL_N- o r i ) N, ► i cy
;>' Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
f
1.0
G, Permission is hereby granted_to dispose of the human remains described above as indicated.
Date Issued Cl 12 Se//6 Registrar of Vital Statistics G3CA..L1yy•Q
(signature)
District Number 5L0 / Place 6 L cL1, `k, A) t7
' ' I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
;
tit Date of Disposition 9 3D//(o Place of Disposition ��n J C.e U, /�r %
2 ` (address)
ILI
tni
tr (section) k �.(lot number) (grave number)
it Name of Sexton or in harge of Premises l/4 C� -mci`
(please print)
Signature U Title C-re .4
(over)
DOH-1555 (02/2004)