Prouty, Thomas 4 Li
NEW YORK STATE DEPARTMENT OF HEALTH ' - ''
Vital Records Section Burial - Transit Permit
Name Fist Middle Las 1 Se
The01� V-rev
ffi Date of Death 1 Age If Veteran of U.S. ArmeJForces,
t�i G— 1.5 -- go I ' '�� War or Dates
.::!:
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1•4 Place • u-ath �� rr Hospital. Institution or
City, own r Village it) c /DLO Street Address 51 £4 p 3$i O'-
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Manner of Death atural Cause E Accident U Homicide n Suicide 0 Undetermined Pending
Circumstances Investigation
Medical Certifier kJame n Jltle
Ke V/U lt?o i 6.N I'/l
Address
9iled A n,_ a dN I f r. yV ci-w c,omh 07 l `ol.., '7-'
Death Certificate District Number Register Nu ber
City, Town or Village `5',S''? ,�
Date �l CP7iviw
tery o�Crematory
❑Burial Q '— /8 - �O l et-e m ct T4'k-t '
��yy Address 0?
1.4. .Cremation V e..Q,rll� -titer .
/
Date Place Remov d
Removal and/or Held
. and/or Address •
Hold
Q Date ; Point of
1 Q Transportation Shipment
a by Common Destination
Carrier
Disinterment Date I Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to J� / Registration Num er
Name of Funeral Home t,�it,,...,� k. Kew/ Po--0(0W Nonft— Cja�^r C�
iiiiii Address S 1
c-* 1-0-01 t 14 — n.. ''7 C
;<<ss< Name of Funeral Firm Making Disposition or to Whom
ta" Remains are Shipped, If Other than Above
aAddress
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Permission is he eb grant to dispose of the human rema'ns describe ove indicated.
Date Issued r 19( Registrar of Vital Statistics
(signature)
District Number it Place L)&ajeonn .j to
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
!I. !
pp Date of Disposition l,J Zt lig Place of Disposition T,,•0.� 440.-�,
w (address)
Cl)
GCC (section) 4(lot num er) (grave number)
Name of Sexton or Person in Charge of Premises l i pL' ,,r,,q„, +i
�� (please print) 1
-
z
W Signature Ut Title [king7,.
(over)
DOH-1555 (9/98)