Warner Tommy J )63
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
-T-OmmukJ Warn
Date of Death Age If Veteran of U.S. Armed Forces,
War or Dates
Place of Death Hospital, Institution or
City, Town or Village C— Street Address -p 1 �
Manner of Death Undetermined ndin
iQ 19 Natural Cause ❑Accident ❑Homicide ❑Suicide ❑ ❑ g
Circumstances Investigation
Medical Certifier Name Title
Address
r 5V
Death Certificate Filed District Number Register Number
City, Town or Village ,�, �yC� � �I
❑Burial Date Cemetery or Crematory
❑Entombment ` c
Address
remation r �y I
Date Place Removed
❑Removal and/or Held
and/or
Address
Hold
tfi _
0 Date Point of
Transportation Shipment
by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home
Address
'S Y
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is herebygranted to dispose of the human remai=desch above as indicated.
Date Issued 2— -)&) Registrar of Vital Statistics
61 (signatqjAK
District Number �I Place @Pyls I IS
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition Place of Disposition 14e.) r�
2 (addre
L!
(section) (lot number) (grave number)
Name of Sexton or Person in Ch ge of Premises 1
► (please print)
Signature Title r
(over)
DOH-1555 (02/2004)
Public Health Law Sec. 4145(2b) _ 3359
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#