Gallup, Bernard r bG")
NEW YORK STATE DEPARTMENT OF HEALTF 4
Vital Records Section Burial - Transit Permit
Name First Middle Last ' Sex
Date of Death ; Age If Veteran of U.S. Armed Forces.
to/2,a. Jaol4 S8 War or Dates i
Place of Death ' Hospital, Institution or
City, Town or Village GLEwiS Street Address C.,E,r,NJ V IS.LL.S i4M .t 'T1',L j
>r Manner of Death El Natural Cause E Accident i Homicide D Suicide fl Undetermined i Pending 1
_ Circumstances _ Investigation 1
Medical Certifier Name _ ^_ ` ` Title —
r �VZA1.-MsZ QEczc,IN c t)
ist Address 1
3-447 0(1 Nit.) S'T AR-Q-EN-‘5gU\z_b 1..N i V3
Death Certificate Filed District Number ��/ Register AlrCity, Town or Village i
Burial �� lad Date J� +� Cemetery or Crematory
/ PIt•1 V I —C MA1-d�9 __
Address
..geremation; LNI UMC.0 L O QUEEN,S N2Sv�c-k 't J \
1
Z __, VDate — Place Removed
Removal and/Or �+eid
n and/or Address
f.---I Hold
0 Date Jtiint of
N7 Transportation Shi merit
a by Common ' Destination
Carrier '
Disinterment ' Date Cemetery Address
nRe►nterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home ti!C y CICt r CII r-)a-k 'l J t_L!)C'i al t far ; ,:
Address -
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
:- Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued }C0 12.2 !l i 4-} Registrar of Vital Statistics LAD QM.trsst A-)
(signature)
District Number 6c�/ Place __ SIP S �llfi.r�Y � �/ _-- -- _ __—
• I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
i-- /
ElDate of Disposition io(L314y Place of Disposition tL_1 C r—dr-�.
2 (address) -
i,U
t (section) of number (grave number(
Name
0 of Sexton or Person in Charge of Premises %r+ ,mot
Z (please print;
LW Signature
Signature t— k — Title_ .00
over)
DOH 1555 (9/98