Quinlan III, Thomas , /
NEW YORK STATE DEPARTMENT OF HEALTH •
Vital Records Section Burial - Transit Permit
E: Name First Mlle Last Sex
/95 C9c,7,(r.�4A z' /41
Date of Death Age If Veteran of U.S. Armed Forces,t r�
/��6 War or Dates 9V3 .—/79
..,.. Place of Death Hospital, Institution r
City, Town or Village 6/i iS,�'i/S /.,,,/ Street Address 1/92.i' S7; 6`G,,�" /T/`�
Manner of Death • `V Undetermined Pending Natural Cause ►� Accident Homicide Suicide
iti
Circumstances Investigation
CI Medical Certifier Name Title
fl' /C/.S gC:W/ Pr'� Ali 12
Addy ss
?‘,�e €1 i'—/ -1W6.y' /5/e947/,/ C7/2.
>' Death Certificate File District Number. Register Num er
<o City, Town or Villag `GZ S//9/S, �,Lf $6 ff/
Date / Cemetery or Crematory_
❑Burial /G� r// v76:A. i 'R&»2,9;7/e
Address
remation f )(7v.fii✓5A -y / /-)2.E C l
gDate / Place Removed
Z❑Removal and/or Held
-�- and/or Address
I Hold
Date Point of
N Q Transportation Shipment
5 by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
`:'s Permit Issued to Registr tion Num er
Name of Funeral Home h?r'9Y/G�9;Q.() a �2�9,e6- . ,t r ?,�,,,qk/71-27 G- 0ll gC
Address
Name of Funeral Firm Making Disposition or to Whom
u" Remains are Shipped, If Other than Above
Address
M
IN
<<' Permission is h reby granted to dispose of the human remains des ribed abo as ' c ted.
Date Issued : 6 Gj__ Registrar of Vital Statistics . -L /y
>< (signature)
«< District Number 560 Place 6/ /LS f19/4 /'/ 420/
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
6 Date of Disposition a, e--04 Place of Disposition r) /4 E`/.'/=(,i C1.; 6fyi4 ,. jZ ' L7
2 (address)
COILI
ACC (se tion) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises ,� L.- } �-l�.kl-/ +--
Z (please print)
r Signature �. �.� Title � _, �____ _____
(over)
DOH-1555 (9/98)