Gallo, Carl V NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
Date of Death Age If Veteran of U.S. Armed Forces,
War or Dates
Place of Death Hospital Institution or
City Town or Ville Street Address �ndelermined
S
Maririer of Death........ .!�fJ:IU. .�. ::::Pend ..:Natural Cause Accident Homicide Suicideg
W Circumstances Investigation
.... ...................... ..... . ... ......... . .. .:......................... ... .......
W Medical Certifier Name Title
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Address
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Death Certificate Filed Distri Number 1 Register Number
City,Town or Village oA A-Lok b, r L .7
Date Cemetery or Crematory
Burial
..............t . .. ........�..:. �1.�2 f:..: � . ..:. t. .. L ....:.Cf , .vur t ec . ...
Cremation Address
Z Date Place Removed
O ❑ Removal and/or Held
F- and/or Hold
Address
N
CL Date Point of
N Transportation by Shipment
in Common Carrier ...::::.... . ....._ . ........ ......
Destination
.... ..............................................................................................................................................................................................................................................................................
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to ti Registration Number
Name of Funeral Firm '
Address
... ............... '� V.lr .. .iil ..
#- Name of Funeral Firm Making Disposition or to Whom
ga Remains are Shipped, If Other than Above
_.............:::. ................................................... ....... ....... .:: :....
� Address
_: ,..:::::: :..:,,. ......... ......
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued NO °lal Registrar of Vital Statistics
(signal e)) 2
District Number 2— PlaceYL/`�LUt � Ali �l� 12-IS—?
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition " A Place of Disposition
2' (address)
Uj
(n (section) (lot number) (grave number)
cc
p; Name of Sexton _Person in Charge of Premises
Z (please print) _� o
W Signature Title r S/
DOH-1555 (10/89) p. 1 of 2 VS-61