Gifford Jr, Leland 1 # ig-11
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
�cinc G i rd Male.
Dale of Death Ag If Veteran of U.S. Armed Forces,
CD - I "7 -- IS Q War or Dates
1,4 Place of Death Hospital, Institutio or
Ci Town or VillageG I( tl 5 l-C (S Street Address (-z I&v' 5 Fa.11 s 1-4-tasP, h I
Manner of Death IN Natural Cause �Accident ❑Homicide ❑Suicide Undetermined Pending
titCircumstances Investigation
ui Medical Certifie Nam Title
c ehri3iophe4-- b
Address
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ath Certificate Filed District Number Register be mr
Cif Town or Village ( ICA I I S 5 oC) 0 7
❑Burial Date /_ ,�pp cemetery or Cremat y
['Entombment — 1`0 t c 1 YAP V LQf.O Cre nic1 1 riI
Address
`Cremation a u eeYI S bV
Date Place Removed
❑Removal and/or Held
and/or
� Address
Cl)
Hold
O Date Point of
5❑Transportation Shipment
O by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to , A Registration Number
Name of Funeral Home C`e-i l)� j,LY1Q�.� 4-JoYY . 'fC- O Ga 1/
Address a-4- `---/1 U r ch £t La 1eLp 1 _u Z.e.-4-nQ /Z 8 1-80
Name of Funeral Firm Making Disposition or to Whom
P
1 Remains are Shipped, If Other than Above
2 Address
M.
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II Permission is hereby granted to dispose of the humarQemains describe above . incl. ated.
(p (�Date Issued O ' G/S Registrar of Vital Statisticstel./1 % (signature)
District Number j- / Place 7 14 "77
J /
-_. :•
I certify that the remains of the decedent identified above were disposed of in accordanc with this permit on:
1-..
z
lU Date of Disposition Place of Disposition
2 (address)
W
(I)
re (section) (lot number) (grave number)
CV
Ci Name of Sexton or Person in Charge of Premises
zz (please print)
iii
Signature Title
(over)
DOH-1555 (02/2004)