Gill, Harry NEW YORK STATE DEPARTMENT OF H E L A TP4 LI Vital Records Section Burial - Transit Permit
NameFirst Middle Last Sex ��
rr Na
Date of Death Age If Veteran of U.S. Armed Forces,
q- )y-z-0 12... g3 1 War or Dates A j o
Place of Death Hospital, Institution or
City. Town r Village h i Street Address
Manner of Death r�� Natural Cause Ej Accident ❑Homicide 0 Suicide ri Undetermined ❑Pending
Circumstances Investigation
riP
Medical Certifier Name Title
Address I 61
(W 151 O Ji.j.L VI .. 14011
Death Certificate File,, /� i Distnc numb. j ' Register Number
a City ow or Village�.�.1 v f'l t 1 e 1 � �LP�J b ( 5—
Date C etery of Crematory
❑Burial I O� -"19 Z_� I Z rm.__r 1 ?_
Add s p Y
Cremation U.Q.Q.nS but_ , NV DQ9 �_
Date Place Removed
0❑Removal and/or Held
�= and/or Address
N Hold
a F Date , Point of
N,o Transportation ` Shipment .
a by Common Destination
Carrier
Disinterment Date Cemetery Address
I
•
❑Reinterment 1 Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Homea_CeA., .._`re.}(7-,, ( " y % 1 nL O Da
Address
a ehwrch h .. LLL .e �A-JY �i(P
' Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped. If Other than Above
Address
Ill
Permission is h re y granted to dispose of the huma a ins described a as . a ed.
Date Issued Q q Registrar of Vital Statistics
(signature)
District Numberr5/05'$ Place J(.c.0 of , "nt 0.....pea.
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
H ,
DIliate of Disposition (U tZ Place of Disposition ,t0c4,44 Cr-4Qrub._
,I (address)
W
CC (section) (lot numb (grave number)
O Name of Sexton or Person in Charge Premises f # L,- i,.�it
Z
41 (please print)
tt! Signature Title Cik/»✓l-'koit
DOH-1555 (10/89) p. 1 of 2 VS-61