Gill, Dwight f , lis # (I. a
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
1 : Name - 'rst l ht ry Middle Last Sex
I (l Male
` ?,, Date of e h ( Age ` If Veteran of U.S. A med Forces,
>y? ') �� 1� s War or Dates �+
ce of De th Hospital, Institut�R n pr �
Ci ,,Town or Villa eG lens l . Street Address(> ergs kQ_/I3 S 1l k I
: ., Manner of Death, Natural Cause Accident Homicide 0 Suicide Undetermined Pending
Circumstances Investigation
Medical Certrfi Q Narrae f�ciN AA a 11 n iA, AA I itle
-' Address
'` t Y gs
.i De at Certificate Fil District Register yj
C.,- Town or Village s 4-col ��j(per � ,1ber�
Date c� "'rAmetery r Crematply
❑Burial -7 (, i ! 1 I T i t1 Q \I l e,u, FYI G? ly
Addr
remation u.Qc r\' bvn� M
Date Place Removed
Z ri Removal i and/or Held
and/or ( Address
5 Hold
0 Date Point of
at Q Transportation 1 Shipment
a by Common Destination
Carrier
Disinterment
Date Cemetery Address
El Reinterment Date 1 Cemetery Address
z vhr Permit Issued to - I Registration Number
} Name of Funeral
{' ' Address,,,
rs c h( .r d1\ & Liu / WJ1) 1 _A t.14
' ' Name of Funeral Firm Making Disposition or to Whom y
Remains are Shipped, If Other than Above
Address
<vh Permission is h eb granted to dispose of the human remains described above as indicated.
h:
' Date Issued A( /' A/.3 Registrar of Vital Statistics Cie
(signature)
>u District Numbeaa/ Place 6 e ,s t 4; i07 /29 '/
` I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
f=
Z Date of Disposition 8 J 1113 Place of Disposition Pot,(1j a tew,`
(address)
Lit
VI
(section) (lot%umber) C.
(grave number)
g Name of Sexton or Person in C4. _harge of P emises ` ;,, e�vaK
Z (please print)
411. Signature Title erlf/v1Kofl
DOH-1555 (10/89) p. 1 of 2 VS-61