Thomas, Dylan NEW YORK STATE DEPARTMENT OF HEALTA ` 1to
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
�NI\an -z, II., S 1-�
iiii Date of Death Age If Veteran of U.S. Armed Forces,
01— ( �13 2..2 War or Dates
Place • •-ath i / Hospital, Institution or
City, ow, or Village �W'� ((ice Street Address
W. Mann- of Death Natural Cause ist Accident []Homicide E3 Suicide El Undetermined �Pending
L. Circumstances Investigation
tgi Medical Certifier Name Title
pi: Jams GCr;e .i Coroner
Address
:Wi14 r✓aS &oo �a &a\ern ry.� J Ito S
Death,,--' 'cate Filedme District Nur>daler -6- Register Number
€ City, ow •r Village 0 l V
OBuna Date Cemetery or Crematory
[]Entombment G� + '`t(� t P•i v.)c k.cAo Co 0M e r t--
Address jJ
Cremation QUL.01b1Sbt.i�y , •1
Date / Pace Removed
g7 Removal and/or Held
and/or Address
tt. Hold
0
0 Date Point of
&a
Transportation Shipment
by Common Destination
75 Carrier
[�Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
_i Permit Issued to Registration Number
Name of Funeral Home 1'n .Qj. y1,1 mer cl .a,ero\ .\r1®'tY\Q- QAp'17
im Address
12?j Mao\ SV . AY5yle t NI 11530q
>'. Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address •
CC
lit
Permission is hereby granted to dispose of the human remains described above as indicated.
:< Date Issued cal rtol,Act'� Registrar of Vital Statistics Q LilicpA,y(J `- •
(signa )
District Number 69S) Place ((„
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition Disposition potato Lwttofj►--p }-1'�'i'i Place of
(address)
ILI
VA
(section) of number) (grave number)
ti Name of Sexton or Person in Charge of Premises It� ,,it
z (plea e print)
) Signature Title C19111'(
(over)
DOH-1555 (02/2004)