Wynn, Gregory NEW YORK STATE DEPARTMENT OF HEAt.TH 1 if "7 Vital Records Section Burial - Transit Permit
Name First iddle Last Sp
�C 0 Al Le-tr..) CJ iJ /1 g2-6-
Date of Death A•- If Veteran of U.S. Arm:• Force ,
t 1(� /l f .Z War or Dates _ ✓d-
ft
P 10-th r ` ,, , _. ,_ .• or
C. Village SZ o enr.osa , Street address 6 io% V PPLv-L.g --/`t i J, / 1
« Man • Death(Natural Cause Accid t $ '• - , r. / Suicide Undetermined Pending
f �� Circumstances Investigation
`„,: Medical Certifier Name �T (� Title
Address /U 2 � i `r-, (&cf,,.Js Feu'r✓v `' /ZP 0
y,oa Death " to Filed District Number egister Number
.i City�f a rr�Vil e C{ U&3N.S Q S�7 /3 1
Date J Cemetery r Cremato
❑Burial /U /7 1 f 1/1-J cf U 6
Address (J ,, Q
{PA Cremation L 019-1 L L;,,1 I vr, o e2'r 4i g Af-L,
Date r Place Removed0-4 n /
❑Removal and/or Held
and/or Address
Hold
a Date 1 Paint of
'in Transportation ( Shipment
,z by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
n. Permit Issued to �t ` Registration Number
Name of Funeral Home/' roi b, &-ker Fecal Home, 01130
Address // Lana y-e,tte (Y. , OUR..WS/W-9 r AJew Vorl-- /G?gY1
Name of Funeral Firm Making Disposition or to Whom
J.: Remains are Shipped, If Other than Above
_ Address
(�R
Permission is hereby granted to dispose of the human remains described abov indicated.
1
Date Issued I o a _x 13 Registrar of Vital Statistics
(signature)
KA
f Place Yy
District Number R (p 7 d---
��f
I certify that the remains of the decedent identified above were disposed of in accordance/with this permit on:
Date of Disposition i0114113 Place of Disposition {� rur ( %rIL"'
(address)
•,• (section) A (lot number)c (grave number)
Name of Sexton or Person i Charge of P emises AI J lh4ff
J (please print)
' Signature 1j_. Title car malt
!( (over)
DOH-1555 (9/98)