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Gonyo, Marvin IT 5g NEW YORK STATE DEPARTMENT OF HEALTH 4 Vital Records Section Burial - Transit Permit a` Name First Middle Last Sex Marvin R. Gonyo Male Date of Death Age If Veteran of U.S. Armed Forces, January 27,2018 80 War or Dates Place of Death Hospital, Institution or City, Town or Village Minerva Street Address 1736 State Route 28N Manner of Death I XI Natural Cause I I Accident I I Homicide Suicide Undetermined Pending al Circumstances Investigation ai Medical Certifier Name Title 01 Glen Chapman Dr. Address ,'PO Box 29,Ticonderoga,NY 12883 Death Certificate Filed District Number Register Number �4' City, Town or Village Minerva 1557 ❑Burial Date Cemetery or Crematory January 30,2018 Pine View Crematory II Entombment Address ©Cremation 21 Quaker Rd., Queensbury, NY 12804 Date Place Removed Z Removal and/or Held and/or Address H Hold Cl) 0 Date Point of yTransportation Shipment 'p by Common Destination Carrier Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Alexander-Baker Funeral Home 00037 Address a 3809 Main Street,Warrensburg, NY 12885 ' Name of Funeral Firm Making Disposition or to Whom }+; Remains are Shipped, If Other than Above 2; Address J Permission is herebygranted dispose h to p of the u m a ins described above as indicated. i °" Date Issued I ?,c_ 1 Z� i F> Registrar of Vital Statistics ` ins _------yk-.cz nk--C3--- --� (signature) , District Number 1557 Place Minerva I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z tu Date of Disposition II 3o i1 a Place of Disposition 1�pp J',L ,_ W (address) p0 (section) /](lot number) (grave number) Name of Sexton or Person in Charge of Premises dr, ,.-it Z (/ease print) W Signature Title 470►4l7.4 (over) DOH-1555 (02/2004)