Gagnon, Francis NEW YORK STATE DEPARTMENT OF HEALTH') �q/
Vital Records Section Burial - Transit Permit
Nam First Middle Last Sex
tranc15 A C CI q n on Mu l e_
Date of Death Age If Veteran of U.S. Armed Forces,
Apr i i 1 ) -.D 15 W War or Dates t -.)T1
faii Place of Death Hospital, Institution or
4( ity)Town or Village\Sky-A-' 4'Pi 1) Street Address We tit/'i.! / (3. r�
a Manner of Death 09 Natural Cause Accide�"tt Homicide 0 Suicide Undetermined Pending
ion
tu Medical Certifier Name Title
Address •
pee Certificate Filed n District Number Register Number
(City, own or Village \Ora 'i ri/lgi 456/ /�o (
0 Burial Date/� ✓ �JJ / JJ mete pr Crema ry n�
Entombment Li— e) --J 5 . r'� 4&') /;;;;;;; Address
«< [ Cremation (,(..LP-P-Sbu.124
Date ace Removed
Z ❑Removal and/or Held
and/or Address
}` Hold
CD
0 Date Point of
Transportation Shipment
0 by Common Destination
Carrier •
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
•
Permit Issued to • Registration Number
Name of Funeral Home B(z`to - r y zzj AO TIM_ /py_- d 6 a/I
Address
011kitil St Viz.b._ LiAzornt� f iy )z)S'l'
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
I
w
P" Permission is hereby granted to dispose of the human remains des ' a ve as di ted.
fli Date Issued 0q-oz 21;cRegistrar of Vital Statistics r'
(signature)
>: District Number cb ai Placekrek.... ek. srr;„,(15
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
LO 1j�, 4
l Date of Disposition 4 J3IiS Place of Disposition ('inf,UL..L ,✓rd,r.
2 (address)
Lu
CO
j (section) /� (lot number (grave number)
ci Name of Sexton or Person in Char a of Premises L 4,-iZ. .°'w`10
( lease print)
4,9 ,
Signature
Title i) r t
(over)
DOH-1555 (02/2004)