Bean, Thomas r
NEW YORK STATE DEPARTMENT OF HEALTH ! `t a
Vital Records Section . Burial - Transit Permit
Name ,..First Middle Last Sex
1 h r%rr,a A L)ea n & tie-
Date of Death Age If Veteran of U.S. Armed Forces,
-- 0 1 - 19 War or Dates k,I 0
I- Place of Death Hospital, Institution or
6 City(TowO or Village I Min rrl I 0, 7_ 1 Street Address 6I t',Q N' ':3 h Z
0 Manner of Death Natural Cause ❑Accident El Homicide ❑Suicide El Undetermined ❑Pending
W Circumstances Investigation
w• Medical Certifier r Name ,� Title
C )fr,n 7pr-e1 I' PA -C_
Address I
) h CI l u,v- 1.11...-K „AA/
Death,Ce ificate Filed District Number Register Number
City,�o Ttwn, r Village J Nita.s,,,N L ,,KQ_ A 5 3
0 Burial Date Cjetery or Crematory
❑Entombment ,-J� . I 1 Lf L \i e a) C.re,y crc f. ,
Address J
(Cremation C- (,Z C C.,1S1,7LA,i -' AJ\f
Date Place Removed
Z❑Removal and/or Held
N and/or Address
ID Hold
0 Date Point of
515❑Transportation Shipment
G by Common Destination
Carrier
El Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home MI i I t,r -Uri,k V.,.1 ktiory nil”
Address �t
PO no( -7 ( 0 1 nd{ t a e1 La KL ,n,y 1/ &1-
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped, If Other than Above
2 Address
cc
W
il` Permission is hereby granted to dispose of the human, etnains describ ,Dove as indicated.
Date Issued / -3 / Registrar of Vital Statistics , P G C (1LL,:
_r (signature)
District Number ;91( 3 Place ic t n al-
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z / '
W Date of Disposition Z12 I 11 Place of Disposition iogicty Lrr�+ertoclu,.-
W (address)
CO
its (section) /01 (lot number) (grave number)
0 Name of Sexton or Person in Charge of Premises L fir, Stnil(M.
Z (p ase print)
iLi Signatures /11 Title (tIZI ,Pt
(over)
DOH-1555 (02/2004)