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May, Gwendolyn NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First / addle Last I Sex Date of Death c j Age/ 4 If Veteran of U.S. Armed Force _ 0;� .fj` -\k -201 LI` 1 (p War or Dates ij 4 _ 1- Place of Death Hos ital, Institution or ;� City, q • •r Village GLeenSo r--4 i reet Add 2,O 2 J Q oymetr Jv t(//Gi 0 Manner of Deathf'Natural Cause j Accident n Homicide 0 Suicide ri Undetermined 0 Pending U1 Circumstances Investigation lU Medical Certifier Name Title Address ©r,v ikDeath ificate Filed District Number i Relisd Number City, own r Village �j �. nS r CL OS 1 c uBurial Date iti / ' Cemetery riii Entombment— o inr .og )110_3 Address Nremation 0 U _ ,-i-N d--pd TGCS "1'C 6, (.10-7 -AIX- _ — Date ! Place Removed '— Z ri❑Removal and/or Held and/or Address Holdtil 1 O { Date 'Point of fili Q Transportation Shipment d by Common Destination Carrier Disinterment Date Cemetery Address 0Reinterment Date Cemetery Address Permit Issued to I Registration Number Name of Funeral Home A, i.:.}, C a i- 1(4- l T1/4o r _;__ _ f3 Address ` t c6.(ky Q t {!k' \ , , G-'A.,L( c n- 0-e./.f , I\1£ tr-„_s y u - ._ V 2 '3(2)L.\ Name of Funeral Firm Making Disposition or to Whom i 1— Remains are Shipped, If Other than Above 2 Address t' t. Permission is hereby granted to dispose of the human emains describ d above as indicated. Date Issued In (o)01� Registrar of Vital Statistics G ` Q LS -- are) District Numbe Place / , I certify that the remains of the decedent identified above were disposed of in ccord ce with this permit on: Z ti! Date of Disposition 9_./9_/9'Place of Disposition - 'A/, /Z. 74 _ 2 (address) 11.E fr (section) of n er) (grave number) Q Name of Sexto r erso C arge of Premises —_ d L J1 ► Z (please print) , U.1 Signatur Title _ '----- ` (over) DOH-1555 (02/2004)