Thornton, Arthur If 7-13
11
NEW YORK STATE DEPARTMENT OF HEALT ''�'`
Vital Records Section Burial - Transit Permit
Name First ()! �(' field l(ref- Easton Sex
itA
Date of Death ` Age c„_ if Veteran of U.S, Armed Forces,
ID V 1H 12-0(�- ° , War or Dates
f"- Place of Death i Hospital, institution or
Ci ,Tow or Village a e e'v,S& 1 Street Address )acccfri Ce r 'k
Manner of Death Undetermined PendingILI
.__._ . Nettie-. Circumstances investigation
Medical Certifier Title
i rate- L siz=iTh PL
Address y
.. r ficate ile_._..__._. w___.._.1.......L. 1 ,_. �t � e� /�� 1 ` ��
Death a ice Filed ; District Number �Register Number
Citr, own r Village C�..teer‘Sbw^a ? i
51a 1 1.?.�f _
('Burial Date 1 [ Cemetery r Crematory
Entombment' r� t-�)�
Address
CremitionJ, -
Date . Place Removed
. -I Removal and/or Held
and/or Address
" Hold
Date Point of
Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
"`, Date Cemetery Address
®Reinterrnent .
Permit Issued to rn /L ( l `_^-- Registration Number
Name of Funeral Home 1" t 0 �"lI''Aq.I .._ �^._."- _0'\- i,D 1 O 46
. ...... ...
Address
i 3(0 (no r Si- + SD,.. c\ S --z( (s r z ga3
Name of Funeral Firm Making Disposition or to WIom
.Remainsware Shiped, If Other than Above
"" Address -�. ___._.._..__._._..._...__.......�._._._.._._._....�..w.�.�_,�__
t
Itt- -_
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10-1`I -).ti VI Registrar of Vital Statistics ALAI. Akke C 't? ._✓
(signature)
District Number 5 e,5 '] Place `-1' v" z.,c it Ui/
I certify that the remains of the decedent identified above were disp sec of in accordance with this permit on:
LDate of Disposition /0/tot li Place of Disposition CRV,4r etir.ctidr r...-
l ti (address)
i
(sect onJ /�/(kt number) c (grave mutter)
do Name of Sexton or Person in Charge of Pre ises F An:lt JG�n �
tpte nt)
W Signature _ Title filimAiv
(over)
DOH-1555 (02/2004)