Fitzgerald, David NEW YORK STATE DEPARTMENT OF HEALTH 11 5-1
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
�a��� C. at,I I/16-k....-1
Date of Death Age I If Veteran of U.S. Armed Forces,
0 l %r o'O13 6 _ ; War or Dates V-c- ' a:1 - -
1- Place of Death Hospital, Institution or
15 City own •r Village t J e,, (e rr �, j Street Address/6-a, ,c9- 7 /� E, 9
a Man - . Death f�7f Natural Cause 0 fcident Homicide Suicide 0 Undetermined Pending
ILI �l Circumstances Investigation
W Medical Certifier Name Title
G
Address - _ - -
A ve--I 1 ./ve,_6/ls age
Death Certificate Filed District Number egister Number
City ow r Village Z-c., kp, (--,-,,,„0 e,, I . 6 a
OBurial Date Cemetery or Crematory /�
❑Entombment 0/-/ -/ — - _:-�./ e_. �✓� mil__(. -i'ei_"f z
Address
Ni,krCremation 4.e. - i r e � I° FQ -
Date r P ac�Ue Removed
Q ORemoval and/or Held
and/or Address
N Hold
0 ( Date ' Point of
35 Q Transportation i Shipment
G by Common Destination
Carrier
Ei
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to - Registration Number
Name of Funeral Home i``Gy►co d . 6( kt"r F t...,l('4 c.. ( I ,C ,)-c.
Address
I I L -{�a V E-1 "IC .>t r (C 1 , Q„cc ( 1 Wit_)(t I / , ;(1, y c,- \( I ,), '( 1 I
Name of Funeral Firm Making Disposition or to Whom
1- Remains are Shipped, If Other than Above __
2 Address
c
W -- -
-- ---------------------
CL Permission is hereby granted to dispose of the human remains scribed above as indicated.
Date Issued j-/gv 3 Registrar of Vital Statistics ail i
(s g re) 1
District Number S' / Place _ y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
14.1 Date of Disposition_- (-Ui3 Place of Disposition - giVti.) a dtw -
(address)
ILI
U)
CC A(section) (lot number)C (grave number)
0 Name of Sexton or Person in Charge o Premises l "�
Z (P print)
W Signature A _ _ Title _ n1�
(over)
DOH-1555 (02/2004)