Luke, Gary It
NEW YORK STATE DEPARTMENT OF HEALTH . -_; ��
Vital Records Section Burial - Transit Permit
=_ Name Firs Middle Last Sex
��
V C i_U _o `-'
iii r Date of Death Age If Veteran of U.S.Armed Forces,
Of]Z 7113 ,� War or Dates
Place of Death Hospital, Institution or
6 .Gity, Wa
ge-e- � he¶ t a r Street Address 77 7 y 4 . a/
a Manner of Death 0 Natural Cause DAccident. Homicide Suicide Undetermined Pending
Circumstances Investigation
LI
tgi Medical Certifier Name �, Title
�;/ee i , ,,„? ..�/ mil./
Address •
/P0Z /dam S!� e- aZ, ���s ��, Y 10280 1
<_ Death .- ii cate Filed District Number Register Number
_ -- . *,� C hes+er 5(�5a B
-< Bu ,I Date Cem ery or Crrematory
II Entombment 5I Z 1/3 d)4 . Y i P l.J 0,re,friaim
Address / /
gili&Cremation al(tier IZd. Chu-e.ei`lsbuu, A Y "Wl- /2�
Date Place Removbd
Removal and/or Held
"! /or Address
# Hold
Date Point of
['Transportation Shipment
by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q Renterment Date Cemetery Address
ggii Permit Issued to Registration Number
Name of Funeral Home Hay n(1f d l•Z a ker Fun era a( -o(ne 0 l 130
:_ Address 11. La4ccye+4e Sir eef
Queensbury Nei you k to $ve-1
<` Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
0
in
` ::z
is hereby ranted to dispose of the human ai s, scri ve as" dicated.
�� � aGj' - /S Registrar of Vital Statistics
(signa re)
»> District Number , &ff,, Place a1-2 (j/ ."jk�/r�i=�' (/ ,
` ` I certify that the remains of the decedent identified ve w re disposed of in dance with this pe on:
tti pos
• Date of Disposition5���� Place of Disposition i ivt/Cir i?,'..A.f ( lir..6,149/dILA/
2 (address)
tn
(section) (grave number)
• Name of Sexton or o n C ge of Premises S lbtlber)
T0.1 a-
a (Plea Malt)
Signature Title ai siu 7i<- /
(over)
DOH-1555 (02/2004)