Oberle, Gay it
NEW YORK STATE DEPARTMENT OF HEALTH 40
Vital Records Section r - ii Burial .- Transit Permit
Am Name First , Middle Last Sex
�c� C , 0berle F
Date of Death / Age c, If Veteran of U.S. Armed Forces,
I l 141' 0� War or Dates
1- P - e of Death (Plosi:74,111blitativri ur
CO : . .. ..- 6lens FLU Uctrat-Aslekess G/enS Falls
tu
anner of Deat Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined El❑Pending
W. Circumstances Investigation
ui Medical Certifier Name �0D r t Spcnzo Title0. A
ID
Address /po� -ark- St. i 6Cf) S Fcl.,i'L s, N7 la 30I
th Certificate Filed District Number Register Number
` ;�City�Towr or Viliage- C:lens Fa II s O/ .30
Fa❑Burial Date //aa/ao/3 -tie Crematory } /
❑Entombment �) v )e
;;�1c Address j� ��- LL.,,
remation CQUCt k er ) Q Guar)s bu:4A-J
Date Place Removed 7
Z❑Removal and/or Held
and/or Address
„I** Hold
0 Date Point of
Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to FT Registration Number
Name of Funeral Home Hcullald �, iSat.er �• 6030
30
Address .
/ I L - S.f. 10u po,n sbu JOW2-i
qilli Name of Funeral Firm M king Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
Ce
ILA
Permission is hereby granted to dispose of the human remains describ d above a 'ndi .
,Ig<i Date Issued 0/ � ��-3 Registrar of Vital Statistics ,�" ` � .�y
(signature)
District Number ��( Place 6/6-ws/ f/ /ag'/
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
to• Date of Disposition (-24-13 Place of Disposition R..eote,.., ci,i,sf 1'
2 (address)
Ili
40
CC (section) (lot number) (grave number)
• Name of Sexton or Person in Ch rge of Premises /1)(14_
�_ s-ivItt4
(please print)
W 4
E:iiSignature Title rei-rwtiDlQ,
(over)
DOH-1555 (02/2004)