Parker, Gary R NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name first Middle ast Sex
dig
Date of Death Age If Veteran of U.S. Armed Forces,
War or Dates es i
Plac of Death _ Hospital, Institution
City, Town o Ila c�h' 7?//Q�/ Street Address ���sa �/�. �S` � T
Manner of Death Natural Cause Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name Title
Address
Death Certificate Filed District Number Register Number
City, Town o Villa GCj h% T hct �1
Date Cemetery or Crematorb
El Burial C toAot
Address_
Cremation
FDate Place Removed
Z❑Removal and/or Held
-.• and/or Address
Hold
Q Date Point of
❑Transportation Shipment
by Common Destination
44. Carrier
Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to J Registration Number
Name of Funeral Home
Address
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human renrialns describq0above as indicated.
Date Issued S/7—%� Registrar of Vital Statistics
signatu
District Number S72�' Place Zq u _ o 42 64.)
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition Place of Disposition E/�/l� if���i
..2 (address)
Lti
0
(section) �/ (lot number) (grave number)
0 Name of Sexton r Person n Charge of P emises 2 L//7
(please print) _
Signature `—' Title %f-2�
DOH-1555 (10/89) p. 1 of 2 VS-61