Beswick, Gertrude NEW YORK STATE DEPARTMENT OF HEALTH I a
Vital Records Section Burial - Transit Permit
Name FirsD Middle6er La Sex
r Ail
Date of eath Age If Veteran of U.S. Arme Forces,
I-el) )1 �/ aloe 9v War or Dates
IH ce of Death Hospital, Institution or / _ // /
Ci , Town or Village l/j/1_c 7a 1 Street Address a�.� Gt/�,� CL�\ /�1/
nner of Death "Natural Cause 0 Accident ❑Homicide ❑Suicide ❑Undetermined Pending
LU Circumstances Investigation
ill Medical Certifier Name Title
Address
O 6,35-6 >° 3s m Ce f? / Ao �/ //c /� 5
» Death Certificate Filed District Number I Register Number
g, Town or Village (t f--r i/ 6 (�.�
Miirial Date / -Cen�tery r Crerfiat
❑Entombment r�b Le.�4f 0) 7 a1 o/3 ��4Le �i-d C/�h-'G // J/-24
Address , I /
[ remation u v c' 1 -e r Aid/ a,_p_g,v-u- U// /`�. LI..F(3/
Date Place Removed
❑Removal and/or Held
and/or Address
= Hold
CA
- 0 Date Point of
Transportation Shipment
a by Common Destination
Carrier
❑Disinterment Date Cemetery Address
iiai❑Renterment Date Cemetery Address
Permit Issued to � Registration Number
Iiiiii Name of Funeral Hom ct /0�'1 -/�� (777o.)77 r�(l`�/�� {� ;�,,j 2 c)
Address
�ff s PAU7le AL° ; y / '/7
11 Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
X Address
iLl
Permission is her by gr nted to dispose of the human remains described above s in ' ted.
il Date Issued , fp / 3 Registrar of Vital Statistics Z4/- ._ .,. 4.
( ignature) Q
District Number c&O/ Place el 1-7 d I/ 61;s.,,,,_, � A9 ii )),0 e,/
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
tit Date of Disposition 7-2'1 0 Place of Disposition 'CALL rt.,,
a (address)
UI
>l
tr (section) 4/ c (lot number) (grave number)
ai Name of Sexton or Person i Charge of Pr miser _ , l,1,.P
Z (please print)
Signature 41Lin, Title clehiA lc"
(over)
DOH-1555 (02/2004)