Thomas Jr, Harold I. . * q6c
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Mid Last Sex
Karol cl a har le s Thorna 4. ,Tr. 'N-1
Date of Death Age If Veteran of U.S. Armed Forces,
OLD ' 9,5 . 2.O1Lo g D 1 War or tcS 7/ CJ,- (L^Jot,r,J ebtaft
Place of Deat Hospita titution
CityIll , Town Villa e �yng.,�., V/(. LLB Street Address .1 it I �,, let ,�v�.
0 Manner of Death 2/Natural Cause El Accident El Homicide ❑Suicide riUndetermined ri Pending
Circumstances Investigation
tg Medical Certifier Name Title
/ �,d-s 4,v-o d�wa- /�13
Address (� �{ r
17 IIenISu,.J J'� Cfr ,r.) UiLLir, / "
Death Certificate._Eiled District Number Regis r Number
City, Town cVillag� L( ,�1 U L L Lr 5' 7 2 -S- 2 5•'-
<:>❑Burial `DaisC . Ce etery or Cr\am
e/atory �r
❑Entombment Z� / i nt Y (ery a^ -Ma I
40 R
Address
`'' ACremation aj Uak-er R071 Qtkeensbu.ry New io r k 1 Lto 44
Date Place Removed
C2❑Removal and/or Held
and/or
I . Address
- Hold
CO
O Date Point of
ti
Q Transportation Shipment
Gs by Common Destination
iili Carrier
Q Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to �-- Registration Number
Name of Funeral Home \4\Q c t-�c' e co..\ 1Ap t`tl t c 11 3(L)
Address
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
a Address
III
'` Permission is hereby ranted to dispose of the human remai e s indicated.
Date Issued (P 27 Ico Registrar of Vital Statistics
rgnature)
District Number 572 Place 1,�C( ,r Cf Ggt/c.Lttc4(C�
l
I certify that the remains of the decedent identified above were disposed of inaccordance with this permit on:
gds.., Lei`"`
l�• Date of Disposition �'Z� `6 Place of Disposition
(address)
ice,
to
Er (section) t
(lot number) (i (grave number)
ti Name of Sexton or Person in Charge of Premises IC J Von
2 ( ease print)
> Signature ""L J/� Title d ��
/` (over)
DOH-1555 (02/2004)