Gerken Sr, Robert -
NEW YORK STATE DEPARTMENT OF HEALTH - 0
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Lo'Z it c,u t, L 1.! SiZ, ,die
Date of Death Age If Veteran of U.S. Armed Forces,
7/'-c- -)0 i 3 DO War or Dates )/e3 LIAJK vd(. A)
}- Place of Death Hospital, Institution or f i.)/f0run!-lC.dc, Pe-Vic PO L
MI City, ow or Village /-/,Q�i2 j To�.ln/ Street Address c': re,t,
o Manner of Death Natural Cause El Accident 1p Homicide El Suicide ri Undetermined ri Pending
W Circumstances Investigation
ill Medical Certifier Name Title
44 �ilL/Alt- AA, if/SCAit-De /ItI
Address
A'64._ ,r.,e,DicA t. C ",Te., . SAiz/,JAL 1ik , iiy /-2 .52
Death Certificate Filed District Numb% Register Number
Cit(ToW1107 Village/ ,7 /erSro,thi) /6
{DBurial Date
// C metery or] ematory
['Entombment ` rfo� � /ILJ „ ''tom ✓ A Tart,e
Address
Cremation gQ/O.(. tilt. /2--0 /Vy, 61Cle,e,hStJri / Z (>Y
Date Place RemovedTT
Z❑Removal and/or Held
and/orlio Address
, Hold
0 Date Point of
0 Q Transportation Shipment
ci by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to / Registration Number
Name of Funeral Home"IX is , et4g% pic ,, C l(7-2,c'
Address /-:---1 y
(
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
,2 Address
CC
is
cL
Permission is hereby granted to dispose of the human r ins described ab ve as indicated.
Date Issued ///2'20,3 Registrar of Vital Statistics i2_,_
(signature)
District Number/ 6 3 Place Village of Saranac Lak
'"` I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k
ill Date of Disposition ►j /13113 Place of Disposition e1 go/ (, c f f,,,,,_
2 (address)
tti
0
cc (section) J (lot number) r, (grave number)
eName of Sexton or Person in Charge of Premises hit:► J Z„r-M(
Z (p ase print)
la Signature L Title CR'mtL
(over)
DOH-1555 (02/2004)