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Gilbert, James
r NEW YORK STATE DEPARTMENT OF HEAL74H- -N 37b Vital Records Section Burial - Transit Permit Name First � Middle ^ 1 11_ - rt Last Sex TcurMc) I_ Date of Death Age If Veteran of U.S. Armed Forces, 5 -3-2.015 (oB War or Dates N)D t- Place of Death ,. ,- 3'" Hospital, Institution or , 1__ Z City, Town or Villa K "i Egg` < ' 16 61 t I Street Address C 1 115 �S ► Izc ( Manner of Death{,Natural Cause O Accident O Homicide O Suicide 0 Undet rmined 0 Pending LV Circumstances Investigation W Medical Certifier Name Title a R /C G-e►-1 o,rt s M D Address BScL e c.-i-rAdy Death Certificate Filed pistrict Number Regi ster Number Ril City, Town or Village c' .- „6` ,_,; L-1 (( OBurial Date C �, etery,ol Cremato Wi ❑Entombment 5-J- ZO (J ► I r)P VIC4_) l � Address ®Cremation Qi.t U.Y15 hik.rt Date _) PIa& Removed Z Removal and/or Held 2❑and/or Address 1:: Hold fin 0 Date Point of fii O Transportation Shipment G by Common Destination Carrier El Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to t� Registration Number Name of Funeral Home k3r-e:�,yt,r- t-uy a i-1-0 vy e inc. (D©an Address Al- 0)1 u,rCh t L-a Z-e,rnQ AN 7 /?g l (' Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address lid tip 97 Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued S- S-- I J Registrar of Vital Statistics ;.1 € (signature) District Numbe, , I. Y \q Place >_:::' I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: is Date of Disposition g l°l i l a' Place of Disposition b..,� o;, 2 (address) 0 ea (section) ,4 tlot n mber) (grave number) . Name of Sexton or Person in Charge of Premises t"• Ev* Z I (please print) SignatureTitle Ow,rip- . (over) DOH-1555 (02/2004)