Young, Gary 4,,,,v,. . It , 43
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First iddle Last S
�Cl y k O K�Date of Death - 7 Age f If Veteran of U.S. Armed rces,
/i 7', War or Dates
Place th Hospital, Institution or
Ci , T wn o Village AL� Street Address `f`�'30 S" - S Li a f'z
▪ Man er eath Natural Cause Accident ❑Homicide ❑SuicidW. e Undetermined Pending
Circumstances Investigation
ILI Medical Certifier Narp.e Title
onsbCI 4---t,e._.. P 1 I et.'1 e re....
Address
I 02-- Pi,f 4 Yc Z.:,--,--...----/---0---"7---' .
Deat a cate Filed ,, jj District Number _ / Register Number
City, ow r Village J-1��� Li- ' 3
❑Burial Date _ Cemetery orI rematory
❑Entombment Address A p f�
Cremation ,.�cA N ..v. A.)C._ '1".,
Date ,� Place Remo
Z, ri Removal and/or Held
and/or
Address
V.
▪ Hold
VIDP Date Point of
t�
t 0 Transportation Shipment
5 by Common Destination
iim Carrier
❑Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home S M:oft— ,v n C.i-t' fiorc.---- G7 p
Address A GrMi• 4V j 1. /U i 1 k �Z
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
tt
cL
` Permission is hereby granted to dispose of the human re ins described above as indicted.
iiiiiiiiii Date Issued 5.- do/q Registrar of Vital Statistics 6
(signature)
District Number t/Scjg Place g
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
z
I I Date of Disposition ;5-1-Icj Place of Disposition ems,(I. J i,'w,Isr-,r--
(address)
ILI
at
C (section) (lot number) (grave number)
a. Name of Sexton or Person i Charge of Premises 1 ntfi
lease print)
• Signature 4 Title agmAlre
(over)
DOH-1555 (02/2004)