Thomson, Nancy w l
NEW YORK STATE DEPARTMENT OF HEALTH 4' h 2
Vital Records Section Burial - Transit Permit
3
Name First I Middle Last Sex
o VEmAt
Date of Death Age If Veteran of U.S. Armed orces,
;;;;;; VS EL‘ 1 ) .;)-o-Cit0 WI War or Dates NI A
Place of Death Hospital, Institution or '
City, Town i3 n L-r-b\O LApyi N c -- Street Address 1 fl AD
Manner of Death❑Natural Cause ❑Accident ❑Homicide ❑Suicide ❑ Undetermined 119RPending
LA/ Circumstances Investigation
w Medical Certifier Name Title
CI
AddrKt R es Il',A MIC.�AEL_ `1(jC
s
SG ,e>Ro A 'I'. ts3/ -TFIQ y'O2t a `
Death Certificate Filed District NumNumber" Register pimber
G-ity; Town err Vtffage G D L`17)1'3 p I 0 G 57o S
❑Burial Date �E���et�ery�-e�Crematory
['Entombment 99 c'C 19 ) b(o 11'v 7 v L E(D 6 .-C-ry\{TbKilR Y1�_)
A ress
remation q U Ptv'C-- _. __9 �' (A E,EIUS.&U `�'(1 t Q O 4
Date ) Place Removed
Z❑Removal and/or Held
fit and/or Address
F= Hold
CA
O Date Point of
ei❑Transportation Shipment
0 by Common Destination
Carrier
El Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to Registration Number
R. Name of Funeral Home F) 1 y„C C i i IC
Address ,,i�'j L
cAC `-PneQi Lf T-, LAKE e,yn 1 aVN-s'
gEp Name of Funeral Firm Making Disposition or to V�lhom ,
I Remains are Shipped, If Other than Above
2 Address
#t
ILI
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued i 9. , (g 4O Registrar of Vital Statistics i _ , ,,, ` 7y"`s
_ 1.--)Ce_
(signature)
District Number b PlaceijOLL-6-1,,\
'" I certify that the remains of the decedent identified above were disposed of it accordance wi this permit on:
,
al Date of Disposition I)jao/vi. Place of Disposition ,At 4 -.! Carr 6 l �.r, ,,,„
W (address)
CC (section) (lot number) (grave number)
O C
its Name of Sexton or Person in Charge of Premises `1 r s Se Writ L�
�� (please print)
I Signature � - Title ( .t" }G,r
(over)
DOH-1555 (02/2004)