Gilmour, Edward NEW YORK STATE DEPARTMENT OF HEALTH , i►
°3
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
I Male.
t,�,�0.�r'd E Ca !Mint
Date o�Death Ag If Veteran of U.S. Armed Forces,
`I `07,3'o�Ql4 B4 War or DateskJo
1 Place of Death Hospital, Institution or
z OD, Town or Village Street Address
G �at�5 ? y„ R ne5 at GknS Fi fps
Manner of Death 1 Natural Cause n Accident D Homicide n Suicide Undetermined Pending
iiiCircumstances Investigation
Medical Certifier 1,, Name Title
D
Addres`s_ - + ,� /� ,�
ath Certificate Fi �t��1s � I�S�l�1 v
le ! / District Number Register Number
City Town or Village( !u' Fans s �h7ODi L. 67,
Burial Date �a Gemete V or Crematory
[ Entmbmet tep1 �t�o I re. teth ! c`D
Address50< 5gCremation 0S buy �
Date J) (Place Removed
9 Z❑Removal and/or Held
and/or Address
1*. Hold
ti'x
0 Date Point of
05 Q Transportation Shipment
0 by Common Destination
Carrier
n Disinterment Date Cemetery Address
n Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home ra0ee - _,. alL 1.:7Q! 1 C, CO I
Address Q± ChL<,y a bike, Luzk,rn.p_., ���Name of Funeral Firm Making Disposition or to Whom
4.
,
ids Remains are Shipped, If Other than Above
2 Address
i
til
Permission is hereby ranted to dispose of the human re ains de cribed ab ve as indi• ated.
Date Issued c Registrar of Vital Statistics 407_y- . 612,._p
(signature) l
District Number 568/ Place et , or r km5 I/5
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z.
(.,
:tit Date of Disposition i(�(/y Place of Disposition ��t� n rL.
w (address)
to
is (section) (lot number) (grave number)
d0typ Name of Sexton or Person in Charge of Premises
L.l@Y
z � (please print)
l Signature U! ,L' Title CfN-wli4l7t
(over)
DOH-1555 (02/2004)