Ciamma, Thomas NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
iiig Date of Death Age If Veteran of U.S. Armed Forces,
tt y�: War or Dates
._:::>. is I sa.i. f ! '-3 y A =t '�, t u i q 4 i
Place of Death Hospital, Institution or
City, Town or Village , Street Address ,.y,.,, i ,"„ i:1.i;
Manner of Death, Natural Cause El Accident 0 Homicide Ei Suicide Undetermined Pending
Circumstances Investigation
iii
Medical Certifier Name Title
Address
Death Certificate Filed District Number Register Number
Mii City, Town or Village i-,ha ;.::•kii::-1 : ,:::;_:
Date Cemetery or Crematory
Burial
Address
-:..:Cremation
t.i i:y.:t.i`t'a t.%tj..,_Y 7 "I;=
Date Place Removed
2 El Removal and/or Held
and/or Address
g Hold
0 Date Point of
cani❑Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date ' Cemetery Address
Permit Issued to Registration Number
:, Name of unera Home •..�: L• I t. •; f i..;:i<. •� Lam: Its}.;.1- et..�y_ •..::yj-i i';�L_l ( a:i?.:R...a-...I
IIIIIII Address
I-u-•« !sti t ems,t t.�,.r�:a Y '-.i-t.do-{ t f i,;!-k '•-i,-',•, t Ivi .:1,, ;,.:r t ;=H1-r i-,
g Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
iiii
rg
Permission is hereby granted to_dispose of the human re ains describe ab e as indicated.
iiiiii Date Issuedo,•1 /r";;i /_ �3:. i Registrar of Vital Statistics
(signat
:i]iiiii District Number35 Place i- -�L•—• - -.i)
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Dispositionp2P- Place of Disposition P,i/stk--1/4-4.) ,/'.EMJ47/�7 /1!J/77
2 (address)
w
U)
CC (section) ,)t o b ) J (grave number)
0 Name of Sexton or Person in Charge of Premises 1FD o,Ill D M
Z (please print) T.
W Signature &,_ ,al.,,s"� Title G/ 71//' 7Q/}( l7/ / '
DOH-1555 (10/89) p. 1 of 2 VS-61