Gallone, Martha NEW YORK STATE DEPARTMENT OF HEALTI ° ') f 3°Z
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Date of Death Age If Veteran of U.S. Armed Forces,
OS I( I lad 13 8.S War or Dates
. Place Death Hospital, Institution or
City Tow or Village G RA NV 11-Lb Street Address
141
Manner of Death 'Natural Cause Accident 0 Homicide El Suicide riUndetermined n Pending
Circumstances Investigation
ILI Medical Certifier Name Title
0 C.AgL P CkL R. Pi\'D
Address
-18 VI- 2r 1`iq vvESi PAwte'(, -r-
in
Death Certificate Filed _ District Number F,egister_Number
City, own or Village �rAN J 1t�u S'7Sb a�
'' ❑Burial Date Cemetery or Crematory
❑Entombment 0 la y Iao 1) P I'v e d I Tt C Q�r/A T0Eu;rig
Address
iiiiiN Cremation &t.,tiO/)Si i)R`l WI
Date Place Removed
❑Removal and/or Held
and/or Address
tt Hold
W
0 Date Point of
in
t Transportation Shipment
C by Common Destination
Carrier
Disinterment Date Cemetery Address
::i0 ElReinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home : 11.CTON -m cb QrO Y T f-V NER/4i_ 4om lw 10c OD i y
Address
ci Pi NE ST C140S1- TOLA1t 0'4 I sl1
itiiii Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
CC
LU
` Permission is hereby granted to dispose of the human remains described above as indicated.
gi Date Issued b s-/ ) o J 3 Registrar of Vital Statistics iv /r I avail
(signature)
Iiii District Number 6-1 styPlace -rl)ul& p F 6(2}1-NJILLC
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k
ill Date of Disposition 6-/24/(3 Place of Disposition natJtw L e it c u+v`
(address)
Ili
fa
CC (section) (lot number)(` (grave number)
1
i Name of Sexton or Person in Charge f Premises o ek"4ht
2 (please print)
jij
Signature IlL Title C e n►,�
(over)
DOH-1555 (02/2004)