Huluebosch, Thomas NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First4
Middle W Last ?/4/1.he,hSex
0-)1 (...J
jex
Date of Death Age If Veteran of U.S. Armed Forces,
*3// O/(O gr War or Dates ivp-rt
14 Place of Death /� / Hospital, Institution or
City, Town or Village U G r �/15y Street Address E ,l�,mc�.d e-e_/ iC'j,:
Ui a. Manner of Death Natura Cause Accident Homicide 0 Suicide ]]Undetermined Pending
if,/ Circumstances Investigation
la Medical Certifier Name .-, i //�- Title// b
Address //
D
/ T / it
avi---d
:::::
E.::,i, Death Certificate Filed i / District Number Register Number
City, Town or Village /D c
IJBurial Date
�j 47 Cemete or CCrem tory
Entombment D �l C'l 7, n 1 ixel 6.-/ 11-L 9
Address �r
['Cremation �1, oil S� N
Date / / Place Removed
Removal and/or Held
and/or Address
w" Hold
fin
0 Date Point of
'Z`E Transportation Shipment
C by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to �^ , Registration Number
liiii Name of Funeral HomeS /71- I O rr) c///1/A.A. R/c.4. /ZC-41.4..a1 4 Q / .5n
ZiE Address
Name of Funeral Firm ht-„i
Disposition or to Whom /
f Remains are Shipped, If Other than Above
';; Address
2
ILI
P` Permission is h reby granted to dispose of the human ain es ibed above as indicated.
Date Issued '� t0 Zb/GI Registrar of Vital Statistics
/ �,%�'`/f�
L(srgnature)
District Number /�/0 Place 7/
>;..;.: I certify that the remains of t e decedent iden ied above were disposed of in accordance with this permit on:
1,11 Date of Disposition �1�O itPlace of Disposition 4-1L1p .3
(ode )
/
ILI
tfl
ir section) 1, lettj ber) (grave number)
Name of Sexton o Pers in Charge of Premises
(please print)
Signature Title
(over)
DOH-1555 (02/2004)