Thomas Sr., Lowell I . r „
NEW YORK STATE DEPARTMENT OF HEALTH ,-
Vital Records Section Burial - Transit Permit
NamqFirst Middle Last Sex
OLOe1 ' f T9mas Sr ! aie
Date of Death I Age If Veteran of U.S. Armed Forces,
— l ( `�O I� i � War or Dates IC)S-7 - t le
0
7, Place of Death Hospital, Institution or
r"'Ei` City. or or Village Sit/lV C.re I Street Address L 1 5 ,.Lt.rr&y
Manner of Death Natural Cause Accident Homicide [�Suicide Undetermined Pending
Circumstances Investigation
tu Medical Certifier Name Title
1 Address
Death rtificate Fi�lejda.rre1bu i{ District u per
v Ciez 1 5&' Register Number
ti .gig City, own r Village DC(
i (�� f� 3
❑Burial DateDvl 1 'v1£} I I I1 etcry. V /er al
.1, Address
cremation! {-, f\, /
ZDate s! Plac Removed
0Removal ' and/or Held
and/or Address
gHold
0 'l Date ` Point of
to Q Transportation Shipment
0 by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
3
Permit Issued to Registration Number
'i Name of Funeral Home _ 1`1C. 0D3--i I
Address c2+ Chiktd 5t
La-k-k-_____U2-ea7X, AN / 2.8 46
7 Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
4
Permission is hereby granted to dispose of the human sins describe a ove as Intl cated.
Date Issued 9 —J'7 i -1 Registrar of Vital Statistics
.' (signature) ,,
District Number Place 0i t�� O 1� Creek
I�
1. I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition liZIIn Place of Disposition , ,It0i,.,. aid W
is k,,.,
a (address)
W
tr (section) Iot ber) (grave number)
0 Name of Sexton or Person in Charge f Premises0 1n tu s
;��+�
Z
(please print)
Ui Signature Title tteI.
DOH-1555 (10/89) p. 1 of 2 VS-61