Gleason, Floyd NEW YORK`JfA1EPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name FirstF toy
01 y ... Middle (lj eL,�s. 10() Sexy n
Date o De t1} AgeQ'(� If Veteran of U.S. Armed Forces,
I 2._ p— t War or Dates .A)l{a-
Place of Deat Hospital, Institution or II
City, Town o Village L,era n.4 p c 6 CZtreet Addre 2 Li /e UAJT 1.,� Uf b-i ljK_
a Manner of Death Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
fa Circumstances Investigation
tu Medical Certifier NameTit
pa in bv.rw
o
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::::: AddrerSs-06) Ea Ii i n eI (%aaZ. c J7 1" " /
Death Certific�� led J
��� le
(�Cotyiell,
i tr t Nu� ar,�' Register Number
City, Town or illage _2
"21$urial bate l C ete rr Cremat
Entombment 6 /( Z '�/T - (`'�'-1`/7 LI.0 C��,
Address
---.tEiCremation a, t3-c-nd>o j-3 t) f
Date PI a fiemoved
.17
❑Removal and/or Held
and/or Address
!= Hold
44
Date Point of
hTransportation Shipment
a by Common Destination
Carrier
❑Disinterment Date Cemetery Address
j ❑Reinterment Date Cemetery Address
Permit Issued to Maynard D.Baker Amend Home Registration Number
Name of Funeral Home itLantyetfet /
Address
nDiYYryry Ny ,,
Name of Funeral Firm Making Dispposifidti or to om
Remains are Shipped, If Other than Above
Address
12
in
Permission is hereby ranted to dispose of the human remains described above as indicated.
Date Issued } Registrar of Vital Statistics dzt______,
(signature)
INi District Number 5 7 Z I Place V 1 I / 61 C- Ot- Cam hvi dQL
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
1
2
Iti Date of Disposition 6/2 0/1 2 Place of Disposition Mt. Herman Cemetery
is (address)
tti
W. Family Plot
rr (section) (lot number) (grave number)
CI Name of Sexton or Person ' harge of Premises Michael Genier
e (please print)
Signature Title superintendent
(over)
DOH-1555 (02/2004)