Crounse, Gregory NEW YORK STATE DEPARTMENT OF HEALTH 4 4 31
Vital Records Section Burial - Transit rermit
Name First Middle A Last Se
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Date of Death Age If Veteran of U.S. Armed Forces,
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- 0 \ - U \ 0 War or Dates
44 Place of Death Hospital, Institution or •
W City(rov or Village Street Address `33 7 Net' Stvort_ PA
0 Manner of Death rNatural Ca El Accident 0 Homicide El Suicide Undetermined Pending
W Circumstances Investigation_
iti Medical Certifier Name Title
Address
; Death -uficate Filed District Num eC r. , Register umber
Tow g •. -- c5 4-' 0 a
<>❑Burial Date C etelry or Crematory
in❑Entombment Address ^�J 70 g �S�S�0 j-Q c��9�Y��
•
lilt Cremation
Date -J Place Removed
P❑Removal I and/or Held
and/or Address
1"` Hold
fa
0 Date Poke of
to Li Transportation Shipment
C by Common Destination
Carrier
s; ❑Disinterment Date Cemetery Address
in
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home n Y� `C(t, WCb, c
Address
Name of Funeral Firm Making Disposition or to Whom
1 Remains are Shipped, If Other than Above
Address •
tr.
UI
9.. Permission is hereby granted to dispose of the human remains describ ov s indicated.
illiig Date Issued (j") -O y \( Registrar of Vital Statistics
(signature)
District Number Placi-- ) /JCL,.. / ! 1,Y
,;<::: I certify that the remains of the decedent identified above were disposed of in acc rdance with this permit on:
Z (� �`
lI Date of Disposition ") (Sit) Place of Disposition k`',u,�t� d ►.—.&
C
2 (address)
Ui
a (section) (lo number- (grave number)
ta Name of Sexton or Person i harge of Pr ises "";a. 'I -- efk y.d�
(J,lease print)
Signature Title
(over)
DOH-1555 (02/2004)