Gillams, Rozeter oFNEW YORK STATE DEPARTMENT OF HEALTH r" ti
Vital Records Section Burial - Transit Permit
Name First • Middle Last Sex`o ze-i-ei M on-1-e-z 6-1- I I am5 F
si Date of DeathAge If Veteran of U.S.Armed Forces
D 7J l E0 20 1 3L 3 War or Dates N
of Death
Glensa LE, /�/. ct secCGrac.e
Manner of Deathfra Cause [j�t Accident 0 Homicide [ 1 Suicide ii Undetermined ri Pending
Ili I—I Circumstances Investigation
igi Medical Certifier Name Title
'ar 6
Address
/02 !Park st-. GIe,r6 Fat L5 iC!-'1 o 1
Death Certificate Fled [3istrict Number Register Number
:. � GIeii FQ LDS � '"6Dl .,....,(13
Burial Date Cemetery or Crematory / /'
❑Entombment Addr0 7 J 1 5/20 I f t Y a o V e .c 40yy
ess
Cremation (,{� [ Ll .(35 rv( /v r/, /2.,D1/
Date i P ace Removed .1
gEl Removal and/or Held
�Hold
Address
46 Date Point of
Sic,0 Transportation Shipment
eit by Common Destination
Carrier
El
Disinterment Date Cemetery Address
Reinternent Date Cemetery Address
Permit Issued to Registration Number
`: � Name of Funeral Home Hal nofd "D.Z a ker F -'eccf I Horne. 01 110
> _ Address 1\ La4cye44e Sired, Queensbury , New yor- lc 1a1 $0y
gil Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
i
Permission is h by s granted to dispose of the human Iemains d "bed ab ve as indi
-A Date Issued 7,P9/3 Registrar of Vital Statistics �
(signature)
iig District NumberS6a/ Place 647.3 (/j j/ onv
I certify that the remains of the decedent identified above wer isposed of in accordance with this permit on:
i
,;Ell Date of Disposition 1-ZIT; Place of Disposition u� ( r
1 (address)
�-,
2
tip
ir (section) number) (grave number)
Name of Sexton or Per in Charge of remises 71 e afi
Z P Print)
11
> Signature I Title Citellinida
(over)
DOH-1555 (02/2004)