Gibbons, Patricia NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
�V-............:.....:: )�g . .: - s 1 luDate of Death e If Veteran of U.S.Armed Forces
War or Dates —_._____
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Place of D at Hospital Institution or
W City Town or Village Street Address
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Manner of Death Natural Cause Accident Homicide Suicide Undetermined Pending
.
Circumstances Investigation
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W, Medical Certifier Name ,.� ,. Title
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Address
Death Certificate Filed District Number Register Number
City,Town or Village C ALL\
Date Cemetery or Crematory
❑Burial
�remaUon
Address J.....::.....:::
09c,�_E ews. c1 1 .�J
Z Dat � lace Removed
2 [] Removal and/or Held
I�- and/or Hold ...
Address
0,::::..............:: .: ......
t� Date Point of
to Transportation by
p, Common Carrier Shipment
Destination
_ .......:. .. .:..... ..............
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Firm
cE .1.... .. etc. DIg : 1 ,
Address
W, Name of Funeral Firm Making Disposition or Whom
g Remains are Shipped, If Other than Above
.:::::. :::: ...........:::............:
...Address
W:
.: ....
Permission is hereby granted to dispose of the hum remains described above as indicated.
Date Issued 3—/ - 1 Registrar of Vital Statistics�4
(signature)
District Number Place .��
I certify that the remains of the decedent identified above were disposed of in ac rdance with this permit on:
t`
W Date of Disposition �'� `7 Place of Disposition d i%Vim j�O Lf ?/i�i �/ ZI-JA 1
(address)
u1'
Cl) (section) (lot number) (grave number)
p Name of Sexton r Person in Charge of Premises
Z' {please print)
W Signature. r Title /1�J,d ��/` / r
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DOH-1555 (10/89) p. 1 of 2 VS-61