Sawyer Jr, Gary NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records section 't - .: Burial - Transit Permit
Name First Middle Last S x
J IH$L;1)QAJ E30-ti J ec-a —1 /L, 6-
Date of Death Age If Veteran of U.S. ed Forces,
,,,` 1 L. /2(o I y . 4 Z Dates ,Jb9-
. «- of Death Hospital, titution or j
s own or Village `-I Cerms Ftai - S. - 'treet ddress t e.)s I`bZ(,
>, ►anner of Deathyfi Natural Cause 0 Accident El Homicide 0 Suicide El Undetermined El Pending
N
Circumstances Investigation
.; Medical Certifier Name Title
6 g-.J n-i2j �i
Y Address
/ _ ��-, @ ,,e-.0.s re-L s /v 1 Z eta i
.. •- - 1 Certificate Filed District Num ( ister
{. 17(
City 'Town or Village Lk3'..v s im c 1 cJ)
Date Cemetery atory Q
ii O Crem Burial /1 2 g / �/ r,A) es'Yi 61-3
• Address
::.1 Cremation C 0 .� , Q V,--A'3 U a, /U . ,
Date - ' Place Removed /
g ri Removal and/or Held and/or Address
Hold
Date I Point of
tR El Transportation j Shipment
a by Common Destination
Carrier •
[�Disinterment Date Cemetery Address
Q Renterment Date Cemetery Address
Permit Issued to ,t Registration Number
Name of Funeral Home/�'C/a-rd b. 'Baker Fw-,eca-/ home_ Ql 130
>s Address // Li fa.yate of. , b u e inbt. - r/U `/vck- l a?SUl
n.
>. Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
jS.
5h(
' Permission is hereby ranted to dispose of the human remains d ve icated.
Date Issued /1' Z ZO/ ‘ Registrar of Vital Statistics
(signature)
S' District Number 5(O/ Place o. €-ti.e /4 /t>'
I certify that the remains of the decedent identified above were disposed of in.accordance with this permit on:
F f (J
5 Date of Disposition i l l3//y Place of Disposition �fi o,L Cs ii 4b"•-/
2 (address)
W
Mt
>C (section) /Alot numb (grave number)
AName of Sexton or Person i Charge of Premises L�f° .- Q
g (please print)
Signature Title Title Cl2tl2,
(over)
DOH-1555 (9/98)