Thompson, Robert # '7 F✓
NEW YORK STATE DEPARTMENT OF HEALTH
. Vital Records Sections Burial.- Transit Permit
i:i. Cl Name First Middle La Sex
ar ( U dHc Su fi
Date of.Death > Age If Veteran of-U.S. Armed Force ,
1 ►3, an)n (9.) War or Dates
P - - of Death / Hospital, Institution or
..110, own or Village (9Lei c- a) Street Address l`LC-4; -f- .ik' ii>c
0: • anner of Death um Natural Cause 0 Accident 0 Homicide 0 Suicide � —PendingUndetermined " ending
t Circumstances —Investigation
W Medical Certifier Name f Title
Address
m 1°)— A t 4 : 4 P.,/,lc-,, 6/a45----Pi-- Avr /.. E9Y,
a ertificate Filed District u r i Register Number
m. -,
City own or Village C Le4 - 11 5 579- \ le 5-
>> LlBurial Date . ( / y Cemetery or Cremato
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®/ , a5, � ‘4cv.c_....s L-t ' 1
:DEntombment Address yt i✓
. fli Cremation f �.�e� S,y r� N� (ate
Date Place Removed
Z ❑Removal and/or Held
9 and/or Address
: Hold
.0 Date Point of
Q Transportation Shipment
_.Q by Common Destination
Carrier
•
Q Disinterment Date Cemetery Address
`::: Q Reinterrment Date Cemetery Address
Permit Issued to
Registration Number
• : Name of Funeral Home Pe-A44,vorc— tA1 u - T-ica .7-L bc'`tzt
Address —7 lf r ANi, C ;„ ai Y / . .` ?...
;> Name of Funeral Firm Making Disposition or to Whom
14 Remains are Shipped, If Other than Above
. 2 Address .
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us
4, Permission is hereby granted to dispose of the human remains descri d above s inn� ed.
Date Issued l o da/& Registrar of Vital Statistics / " llw�
Y (signature)
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: District Number s6 c2/ Place 4a-ntfi°k I (. ) /q T
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI Date of Disposition it/i 1l /b Place of Disposition R'ilitivhAi ettratto n.•'^-
2 (address)
tl
CC (section) i(lot number)c (grave number)
iName of Sexton or Person in Charge f Premises " �.3�1041
Z /�, (pl se print)
• a - Title t� �
Signature
(over)
•
DOH-1555 (02/2004) •