Gilooly, John SZS'
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First—ok v\ Middle Last Sex
t '�
6. oo[ l/ fric
Date of Death Age If Veteran of U.S. Armed Fotces, .46
! _ /
cf— 3 — �/3 ? War or Dates A rev- C� G
Place of Death 1 Hospital, Institution or L
City own o, Village l (J 1 1 1 Street Address I 4/ / II Cw'y1 re y C
a Man -r o Death r` Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined Pending
Circumstances Investigation
la Medical Certifier Name Title
Doc-kr
Address 15 I r►ap42 11 7_5 • m) /Zsa,
Death Certificate Filed ' n '< �� District Nym / Register tuber
City(Towr�Village LJ f /� g (.,1�
❑Burial Date �'f ✓ r(/� J Cemet ry or Crematory
El Entombment ` 5 rt re U ►e ui CCeNt Ce-i-or
Address 4_9
/� f (U;Cremation f Lta - (,yl (�1��.,v„S,Our /
Date Place Removed T
K El❑Removal and/or Held
and/or Address
t Hold
in
co Date Point of
Di ❑Transportation Shipment
Ei by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Renterment Date _ Cemetery Address
Permit Issued to / y - Registration Number
>_ Name of Funeral Home ( /h l s 1 t),' Fc.coeji ( to OO 3Z y
Address Li0 2 c iI Ve , 55. 1°52 //�., c6g
s Name of Funeral Firm Making Dispositior9or to Whom /�U�
• Remains are Shipped, If Other than Above
• Address
in
Permission is hereb granted to dispose of the human remai described above as indicated.
Date Issued q q Registrar of Vital Statistics a cit,0-?....."-___
(signature)
District Number /15 LePlace lain of tJ/ '
I certify that the remains of the decedent identified above were disposed
tdisposed of in accordance with this permit on:
Lit Date of Disposition $ Place of Disposition 61
(address)
to
cc (section) (I number) S"-hwti (grave number)
el Name of Sexton or Person i Charge o Premises At„
z (please rint)
• Signature _ Title 0201164
(over)
•
DOH-1555 (02/2004)