Gauvin, Nelson t 1 Si°
NEW YORK STATE DEPARTMENT OF HEALTH Burial Records Section Burial - Transit Permit
77 N me I First Middle Last Sex
4:e e-I 5D n ?
_, Date of Death Age If Veteran of U.S. Armed Forces,
7- 1 g-- Zfl 15 8-$4. War or Dates no
Place of Death Hospital, Institution or n
•• ; Ci�t/, ' • , .r Village 1 not tan �-- Street Address c� 1'U rrai+ RA
Manner of Death Natural Cause ❑Accident El Homicide Suicide Q Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name Title
` Ad ress 41
Death Certificate Filed i t District Number Regi yer Number
City,Town or Village 1 nok van LetiLk, Dz (p
Date -.emetery`or Cremato
❑Burial 7-- Z o - l S , C'1 n V i e t,J ma -o
Address
> rt.Cremation ri 5IOlA r
Date Place Re oved
0 Q Removal and/or Held
and/or E Address
Hold
Date Point of
E!Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
::`. Reinterment Date Cemetery Address
�<; Permit Issued to Registration Number
Name of Funeral Home 1i12. 11 ILlikr +hiiz,. ; r'11 qq
�; Addres1,kt incham Laict, ivy 12. 74-c)---
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
sx
Address
j. Permission is hereby granted to dispose of the human a sins desrabove as indicated.
x
L Date Issued 7-/ S'/> Registrar of Vital Statistics 1.21.E
re„
fq ignatur\e)�/
`{ Place j v y
District Number�.� � �/ail. �� /
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
iF p /�
Z Date of Disposition 7Iz•Iir Place of Disposition
a (address) �(` Gr ,,.,
txt
CO
(section) tat Rum ber) (grave number)
g Name of Sexton or Person in Charge of Premises �� Sl+46f-
2 (please print)
40, Signature `ice ( - Title Cy,,i
DOH-1555 (10/89) p. 1 of 2