Judkin, Thomas Tctb
NEW YORK STATE DEPARTMENT OF HEALTH ' 1
Vital Records Section Burial - Transit Permit
Name Fi Mid le t Sex
/% . [ z�,,f, '01cz-C-e
Date of Death g If Veteran of U.S , rmed orces
` Agey �
/ _�< j War or Dates /
}- Place of Death Hospital, Institutioiaif' r L/
z City, Town or Village Street Address ty / >1 /'/ .v0ry � —
lAl
Manner of Death z Natural Cause 0 Accident 0 Homicide 0 Suicide Undetermined e ending
ILI Circumstances Investigation
W Medical Certifier Name � • 1//,� LLc Title
l4 r ,,e& A --- .-- 1-1 ()
Address qj
Death Certificate Filed District Number 1 Regis/ter fpiber
City, Town or Village �, r--.;4 5 `,7S /3
[]Burial Date /�,/ Cemgfpry or�9ematory
❑Entombment /' �i /::Jl4F' U G,�Gf.�% 3r e-4� r-
Address
Cremation ( —fi-t-it",‘c /. -6"- iv ,,. 2`
Date Place"Removed
Removal and/or Held
9.❑and/or
F Address
Hold
UY
0 Date Point of
ti Q Transportation Shipment
G by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home z 7/ V „Cit.) 9,/ -.5—
Address / T 1,2,-,i,--7,- a
/�
Name of Funeral Firm Maki} g Disposition or to Whom
}.:.- Remains are Shipped, If Other than Above
a Address
tX
Lf
fl.. Permission is he by anted to dispose of the human m ins described bove s indicated.
Date Issued Registrar of Vital Statisti trill,/
��� (sig ature)
District Number ) Place ,
"" I certify that the remains of the decedent identified ab were disposed of in accordance with this permit on:
z
ILI Date of Disposition a-ay_ .l ( Place of Disposition pirieui. t,..,). cf''ev►�for u pM
(address)
ILI
VI
I (section) (los�t g'umber) (grave number)
0
a Name of Sexton or Person in C arge of Premises I i`rv,talky ( ne&
W. -4 (please print)
W.
Signature Title Cf`cm aiet f &Al •
(over)
•
DOH-1555 (02/2004)