Bennett, Gail NEW YORK STATE DEPARTMENT OF HEALT$i ' 1 -? `Z5
Vital Records Section " Burial - Transit Permit
Name ,Firsta . Middle Last lxylatk,
ni Date of Death Age f Veteran of U.S. Armed Forces,
(p-7- la (0,5 War or Dates )
}- Place of Death - Hospital, Institution or
• Cit�Town�r Village. 1�L�lAti%�,L Street Address 6, 16 1 as)
• Manner of Death Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
W. Circumstances Investigation
ul Medical Certifier Name Title
'Q e A. £Lti-& kPA -
3
A ress
/o 35-b S :t.. iett_ 3l) \a/ackA tout-t )/t/t/
Death Certificate Filed District Number.,? Register Number
ipEl City,(row�r Village A_ d Q_, r��i �
❑Burial Date etery py Cremapiry
>'❑Entombment U lD - 0 7- a 0 (c, I t V Lt ) C- Q_..(il.Q?'t51.,
Address
mil®Cremation 111 pAL 41 b(A•1'.A-.y , �Y
Date () ' Pla Removed
t ❑Removal and/or Held
and/or Address
=" Hold
0 Date Point of
Q`0 Transportation Shipment
O by Common Destination
in Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
iiiE Permit Issued to Registration Number
Nii Name of Funeral Home)1/1 I11 _ Q(t R q
Address
II t-193 .1 4St. P±-t_ 30 4-ak_tu‘__"_t_s7-y),3 0 Etta_
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
2
Ili
'" Permission is hereby granted to dispose of the human remains described above as indicated.
Mii Date Issued 4 /7• abiZ Registrar of Vital Statistics 0- .
(s. ature)
iiiiiii District Number , 65 3 Place /, )b/,4,J /..4-Ke - / /,/ / ia(F' -
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
1.0
ILI Date of Disposition (Ai la_a_ Place of Disposition .pKUtcv.) �r►wit-or,vr_
(address)
Ili
til
CC (section) A r (lot number " (grave number)
Name of Sexton or Person in Char of Premises [ hr1s1 alulat"
Z (please print)
lti
Signature / V Title Cq MP1.rocL
(over)
DOH-1555 (02/2004)