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Gray, Patrick
to cel NEW YORK STATE DEPARTMENT OF HEALTH, \ • Vital Records Section Burial - Transit Permit Name First -. -Middle /1 Last Sex, V f'61zi c J o pi,0 V(-!/ /�i ✓ Date of Death Age If Veteran of U.S. Armed Forces, 12 - (D -zvf _ S J War or Dates of Death ospital Institution or A rt tir own or Village��o jZS Vt u r e Address /Vi i i �1 rcw/�. • nner of Death ©Natural Cause ❑Accident ❑Homicide ❑Suicide ❑ Undetermined ❑Pending W Circumstances Investigation tu Medical Certifier Name Tile --I U N 61 u,�J -I /i P1w) Address Certificate Filed 4 District Number Register Number City/Town or Village V t-O s v l(-Le 1701 275 aiBurial Date C )tery i remat IZ-1Z--1,o f-l.- ),I,¢ Vita- lid friA I tY ❑Entombment Address I <.;» I remation 2� �V1 G '-R PP • aVE '�Bvt2I, /J/ 12 8 L1 Date / Place Removed ❑griRemoval and/or Held and/or Address tit Hold 11 0 Date Point of Transportation Shipment Et by Common Destination Carrier ❑Disinterment Date Cemetery Address El Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home 1 ► ,Fj. Wyk-All-it fi/itt KM. Rome- 010-19 Address ?Z grk 0 1t'tINAJAl) o � i�W 41� 0 /1.)1 1212-1 '< Name of Funeral Firm Making Disposition or to Whom • Remains are Shipped, If Other than Above . Address Cr w Permission is hereby granted to dispose of the human remain described ab ve as indicated. Date Issued 12/11/12 Registrar of Vital Statistics �.-. ,��J�lAeh.a_ (signature) District Number 1701 Place City of Gloversville I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z ILI Date of Disposition / i-/ 9/lace of Disposition Pit/tCy 1- ��jo /44/ 2 (address) ILU CA CC (section) number) / (grave number) ▪ Name of Sexto r Pe on in rge of Premises "eg 13 Jt vid Z (please print) ili gi: Signature Titled As (over) DOH-1555 (02/2004)