Gilheany, Thelma -ITWYORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name Firs Middle -La S
Date of Death / Age If Veteran of U.S. Armed Forces,
War or Dates
U Place of Death Hospital, Institution or
City own or Village //Xxzz-�
Street Address
anner of Death�atural Cause Accident Homicide Suicide Undetermined Pendin
Circumstances Investigation
Medical Certifier — Name. Title
/1 jkcjdress
» !j . �..
V th Certificate Filed District Number // Register Number
City Town or Village -56 o 1 12 0
Date Ce(netery or Crematory y
❑Burial �"
Address IJ
[�remation
Date P ce emoved
o❑Removal and/or Held
•— and/or Address
Hold
Q Date Point of
%L. Q Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home -51
Address
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is her bGy� 7anted to dispose of the human remains descri/bed�bovv/e�as i cated.
Date Issued , - / / Registrar of Vital Statistics
signature)
District Number S6 0 / Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
f-
Date of Disposition a Place of Disposition 1 lu 6 V % C V V C,1w e i` l t-T("LU
i �1
(address)
LIJ
(section), (lot number) (grave number)
I Name of Sexton or Person in Charge of Premises Al j CA A R L t, e e-Z-
(please print) �
Signature Title r rc M a7-o rli l4 5'S
DOH-1555 (10/89) p. 1 of 2 VS-61