Brunelle, Gary NEW YORK STATE DEPARTMENT OF HEALTH Burial _ Transit Permit
Vital Records Section ..
€< Name First l,dle Last S 1
>< rl i 6LL- f /1ff?,Lf
ill Date of Death I A e I If Veteran of U.S. Armed Forces.
1/ // / I ( War or Dates S'"� — (O �
'` Place o Dea h I H vital Institution or
Ci , Town'a Village u� Q uVLF Street Atictrie 23 y v, �s
Maat Undetermined Pen in
Il tural Cause Q A i e t Homicide ❑Suicide n 9
Circumstances In stigation
xtj Medical Certifier Name Ti e)
'C Pa,./1 r✓L-G� Clia2 611 ✓j/
Address �- /f
gik 3 2-) a�l_„„ n c.0000, )---r- _ Li L,)y-v�,,6
iiii Death ' 'cate Filed i District Nper Register Numb r
City Town r illage 6 lr A �O �- I' '�j
Date Cemetery .r Crematory
>:< ❑Burial / / 1 ! ii L ' i (--tt
L� yi
C �
Address
Cremation��
ZI Date _ f Place Removed
❑Removal I and/or Held
rz and/or ! Address
Hold I
4 ' Date _ Point of
Transportation. Shipment
a by Common Destination - -
Carrier
Q Disinterment Date I Cemetery Address
n Reinterment J
Date .Cemetery Address
Permit Issued to _ I Registration Number
iiig.1 Name of Funeral Home
Address /
Kilii L i�- f3=//U't i L' (j)u�.Z,uS a L{I1 %A' t' y
a12-4P-Name of Funeral Firm Making Disposition or to Whom J
Remains are Shipped. If Other than Above '�
Address
iiU Permission is hereby ranted to dispose of the human remains described 1boove as indicated.
ig Date Issued 1-t I [Li � gistrar of Vital Statistics��_ q, C �Jri-A-,,,,,„,
(sipoatu )
District Number SC E cn Place I ?) 6-4-, O— b. e t-,
' : I certify that the remains of the decedent identified above were disposed of in accordancewith is permit on:
l~ � `�
WDate of Disposition /I 115 'fb Place of Disposition 'E�nuVLir./ rrv,,M.
5 (address)
w -
tX (section) (lot number), . (grave number) -
0 Name of Sexton or Person-in Charge of Premises • L h ib n r J` evi.i4V
• 4 (please print)
111 Signature L Title ('1 H t L
- (over)
DOH-1555 (9/98)
%
e