Gill, Ronald NEW YORK STATE DEPARTMENT OF HEAlhtli #
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Vital Records Section Burial - Transit Permit
Name Av .A'ddle
einel 0 �i fI 612/Y7st ifa.
Date of e p ®�� Age x If Veteran of U.S. Armed Forces,
War or Dates
j- Place ath � Hospital, Institution opt
Z City T w or Village I 1 O(t4'1 ✓�" hi✓ Street Address (,r®L!/J�I 1 ,!.'/✓
Manner of Death❑Natural Cause 0 Accident 0 Homicide 0 Suicide El Undetermined nding
It Circumstances Investigation
ta Medical Certifier Na �� Titi1 ",iZ
i.,/,4'
ddres 2d, / ,‘
,' , ..4/y 6
M. Death ificate sled District Number Register Number
City, To r or Village Cit'- 1 &i 4✓ ✓5,7 I
Date Crrretery r Cremato
Burial ✓�� ��✓� " ✓.. C l .0- ✓t�r/l-l�l
gE['Entombment Address //
ie remation t)� fe/ Re a..�?f�liTf Af,,c7i. /�y�r
Date Place Removed
2❑Removal and/or Held
and/or Address
H Hold
in
0 Date Point of
Transportation Shipment
0 by Common Destination
ia Carrier
❑Disinterment Date Cemetery Address
a Q Reinterment Date Cemetery Address
<: Permit Issued to C /f raj Registration Number
Name of Funeral Hom&�'7k-? j rgIf/ `/-/�HC - 6169✓L✓✓
Address /gii /t S- C. 4�cr��/d Gt/dam .___- /- ✓A/ `)
Name o Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
a Address
CC
LU
Permission is her y gr nted to dispose of the human re ns scribe abo e icated.
Date Issued 7,„)--- Registrar of Vital St istics -
(signature)
District Number [3—s--i Place ~7-0c4,,n 0.fi^ w y1 700 , 1-
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI IIll
Date of Disposition q•iz"it Place of Disposition Pµvicu C,y„-jr0,-,,
2 (address)
at
Cl) (section) 4 Sot number) c (grave number)
0
CI Name of Sexton or Person in Charg of Premises l h rtytft, tkilitz ease print)
f Signature Title WO Pe@it
(over)
DOH-1555 (02/2004)