Langdon, Gary i ff V"3
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
II
' �ary Lee.. Lox clams M
<` Date of Death 1 Age O f If Veteran of U.S. Armed Forces,
Iiii 0+ Z 8'20 f 8 War or Dates .___
Place eath QItNLx�ht�. I Hos ata��tution or
Cit Town r Village treet Addr__es ecd. bq PIL cci .
5 Manner of DeathaNatural Cause D Accident El Homicide 0 Suicide ri Undetermined D Pending
Circumstances Investigation
Medical CertifierIli Name Title.
Address
C t11,l Co..r `SZocc�
Death rtificate Filed
it Ci To r Village Q" -a'f- b SvS'il i I S 3
Date I Cemetery or i-ematory� •
❑Burial /01 -0(8 V irYz lJ tit
.. Cremation, Address Qu atr , Q biA.A.
t Nq I 2-SOLI
Date ? Place Removed
g El Removal I and/or Held
N and/or Address
Hold -
L? Date T Point of
n Transportation i Shipment
a by Common Destination
Carrier _
C Disinterment Date Cemetery Address
::.:: ! 1 Reinterment Date ! Cemetery Address
Permit Issued to ,� l Registration Number
41 Name of Funeral Home(%CL/nard b ct 1ker /- j)ercd Home- 01 ) c
<« Address /i Lrc
'i Name of Funeral Firm Making Disposition or to Whom
akt Remains are Shipped, If Other than Above
44 Address
Uj
1
Permission is hereby granted to dispose of the human remains described above as indicated.
111 Date Issued ,0- -()DIP Registrar of Vital Statistics o-4-1- -ih a.� k. 12.A.A
III (signature)
``a' District Number S kiS 1 Place____ U e e ft S b ti/'
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
E. Date of Disposition I)/t ((' Place of Disposition fl1, L1 Ltitor,..1-.-
a (address)
IV
in
it (section) (grave number)
4 Name of Sexton or Person in Charge of Premises rioAltfoLn.....umbtAe
(please print)
tt. Signature d Title (g;et1\bg
(over)
DOH-1555 (9/98)