Farr, Gary NEW YORK STATE DEPARTMENT OF HEALTH ` 3-1
Vital Records Section Burial - Transit Permit
Name First r Middle Last-,--- Sex i
Date of Death Age If Veteran of U.S. Armed Forces,
11' a3 , 71 War or Dates
ZP . - of Deat/ /' Hospital, Institution or -1„- �
iigr own or Village (>/-�► . Street Address Cg
6, anner of Death Natural Cause ElAccident 0 Homicide 0 Suicide riUndetermined,Ei Pending
laCircumstances Investigation
W Medical Certifier Name Title
1 v 1 e_� VA r - IMF .
Address
ic''' Leotri4 ‘te-t-7--1--a-ii, Xrr /ago/
Certificate Filed , District Number Register Number
Town or Village S6 C� g
Burial Date Cemetery r Crematory
Entombment Address
[ICremation �j/�{_e,,yj•,r Aj�„� %Jr'�
• Date 3 l Place Removed
Z a Removal and/or Held
4. and/or Address
11 Hold
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0 Date Point of
tili 0 Transportation Shipment •
E by Common Destination
Carrier
Q Disinterment Date - Cemetery Address '
g,iQ Reinterment Date Cemetery Address
Permit Issued to ��— Registration Number
Name of Funeral Home �1 S r,:)r� /une_f.. l �i n-# 1,.�. - C�a "t i'1
Address 7y'y .,___. ,2,-,-,.0„...- Atte ",f.4.14.
Name of Funeral Firm Making Disposition or to Whom ) /
f_- Remains are Shipped, If Other than Above
. Address
its
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued S/a /o2n15 R W O..gistrar of Vital Statistics A4 _ LA '
(signature)
District Number 5 GO I Place Id s \\� ' lhi y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
z
tii Date of Disposition SI 2b iI S Place of Disposition PivtA..., Ci` prtiw
(address)
lit
1C (section) J (lot number) (grave number)
CI Name of Sexton or Person in Charge f Premises ,fir✓ th+
Z.
Z (please print)
lE! Signature Title n760 114
(over)
DOH-1555 (02/2004) •