Ullmann, Thomas 0-- * # 3/D
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Date of Death Age If Veteran of U.S. Armed Forces,
4_ 1 Li -- (8 (el War or Dates n D
}- Place of Death `` Hospital, Instituti o
City, Town or Village \r A tiur� I • Street Address U� 3 I il� 4 CL I is
0 Manner of Death Natural Cause (�4 Accident 0 Homicide D Suicide Undetermined Pending
ILL Circumstances Investigation
W Medical Certifier ` I Name Title
CI V1 rAinirk J2 yin 1r,3ScorDr4f--
. .'
1-063Addresst � ,� n
Deat --.ificate Filed l Ll� District_Number Re ister Number
City, owe •r Village iYnci l&v l c. 53
❑Burial Date, - 16_ $ ietery or,Ce bto�
L.�. i -I.JI Yle 1�/1 Ct,, r..)
El Entombment Address
Cremation € )UUJ1 5
Date lace Removed
1 El❑Removal _. and/or Held
r. and/or Address
H Hold
to
O Date ' Point of
�`'0 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 M i 16- 47.kr tra,1 ' +10v' 0 /i-(9
Address 115-1 S R-te_ 1�(t 1�1-�') � 1 2 7�L[ Z-
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
LC
i!
` Permission is hereby granted to dispose of the human ins described above as indicated.
Date Issued 1)to i (3 Registrar of Vital Statistic _ v ` (12e. z, l.4
(signature)
District Number 53 Place ,n d la n I n y
;:: I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
n�
l• Date of Disposition girl.113 Place of Disposition �IDy f"' '
2 (address)
i
CO
CC (section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises
(plfase print)
Signature Title ii40 f--
(over)
DOH-1555 (02/2004)