Gerard, Bernard # 4 g
NEW YORK STATE DEPARTMENT OF HEALTH i
Vital Records Section Burial - Transit Permit
Name first jddle Last ( Sex
Date of Death Ag If Veteran of U.S. Armed orces,
`1 — 1 62 b is , ',3._r War or Dates /\JO_ ...
Place of Death i Hospital, Institutio r �l
: Ci-tyL�ownn r Village Street Address �jtdJTTi( (
r) Manner of Death Na ral Cause AAc�iiHent Homicide Suicide Undetermined Pending
LU Circumstances �Investigation
w Medical Certifier Name Title
C3
Address
Death C rtificate File District Number Register Number
CityQ.ow�r or Village ,t �"G S� a a
Date Ce tery or remator
❑Burial
Addres
Cremation
oy
Date Place R oved
Z❑Removal and/or Held
and/or _ _ . _ ___-.-
Address
Hold
. Date Point of
15 Q Transportation Shipment
G by Common Destination
Carrier
0 Disinterment
Date Cemetery Address
E
Reinterment Date Cemetery Address
Permit Issued to Registration Number
���
Name of Funeral Home AVA-i — l /Address -_ �
G,35-) SfaAt ' 5o 4,x,d_kak. is_-t-ei_._ id 4./c7i,.
Name of Funeral Firm Making Disposition or to Whom
F Remains are Shipped. If Other than Above
il Address T
Ai
Permission is hereby granted to dispose of the human remains described a as indicated.
Date Issued cct//7/cO/� Registrar of Vital Statistics ALA-�c �',
(Si nature)
Place /
District Number 6(fl i ,1 l U'u"^ v d
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
1- ''� ,
W Date of Disposition c1-11-1 2, Place of Disposition �(�kt0,,J 1 -d r,�
2 (address)
W
N
CC (section) lot number) (grave number)
Name of Sexton or Person in Charg of PremisesCI
ry
Z AL
(please print)
Signature Title C-17A74i►4 t ba
DOH-1555 (10/89) p. 1 of 2 VS-61