Thomas, Kathryn to . 1 S/l
r NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name it t c.1 Middle Last Sex
Date of ath 1 j Age If Veteran of U.S. Armed Forces,
ii to (3, az IS -7 0 War or Dates No
Place of eath Hospital, Institution or
City, Town or Village SA.;V C'Jr Street Address 45 M terra Rd
Manner of Death ►`I Natural Cause ❑Accident ❑Homicide ❑Suicide El❑Undet rmined El❑Pending
Circumstances Investigation
Medical Certifier A Name fit Lx 11 M Title
Address
Ands►, Y--, UV,,,,T-Asbik,r1 N')/ IDAss
Death Certificate-Filed Distri ��beer Register Number
City, Town or Village �8
❑Burial Date D6/aa i 1/ Ceknetery_or Crematory
( Vine, U1eui CrelYksofio),
❑Entombment Address J
alCremation QI. /l u-rj ir\Y
Date Place Removed
j El I—'Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
°
Carrier
r
❑Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to � Registration Number
Name of Funeral Home n rC }-uylp _( y u( )y C__ coati
1
Address o7st U LtrC , St Lam - Lt rr )?f b
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human re ins described above as i d.
-:.-t. Date Issued (0 , alaz a Registrar of Vital Statistics �� . )
(signature)
k ; District Number l 052 Place S-107)Li ree Ny
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition (s/pg 0 Place of Disposition -U. ( ,....
(address)
sk
(section) (lot number) C (grave number)
41
Name of Sexton or Person in Charge of Premises tit 5.�..
at (plea print)
Signature Title / oo lM
(over)
DOH-1555 (02/2004)