Hutchins, Thomas NEW YORK STATE DEPARTMENT OF HEALTH , 4 i
Vital Records Section Burial - Transit Permit
>s Name First - ' Middle Last Sex
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Date of Death + Age If Veteran of U.S. Armed Forces,
/o?- 3 6?0 i / -76 War or Dates (q5' I q(p 1
14. Place of Death P.Hospital, Institution or
City(rowpr Village LO n e�,}}-t,CL/ �� Street Address (p i) C )Cta1(� / a
ili
i Manner of Death®Natural Cause DAccident ❑Homicide ❑Suicide ❑Undetermined El Pending
Uri Circumstances Investigation
tu Medical Certifier ame Title
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Address I �j
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Death Certificate Filed District Number . Register Number
CitykToor Village L.0 p qJ L j j-c _- 0 5(il
'«`:❑Burial Date Ceix etery or Crematory
❑Entombment i o� J __J,c) i i -H ► c V i C;w =f m e i c: r -Li
Address
Cremation Lj l,l.LE--t' 'S ' .Z,---Z f J `�
Date J Place Removed
Z Removal and/or Held
❑and/oldor
H Address
to
0 Date Point of
tZ Transportation Shipment
0 by Common Destination
Carrier
El Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M i 1 I�— ,L44 Q t---& I -1 o'vL 0 j j
Address 4
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Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
w
f` Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued ) f aj)c) 011 Registrar of Vital Statistics ALI-Le)
signature)
District Numbert056,, Place I0 wn Lrl qq La -
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI Date of Disposition pec S+ idyl Place of Disposition Vt,,i01-Cut cArt-difo r/u►.,
(aess)
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CC (section) /fr (lot number)r— (grave number)
Name of Sexton or Person in Charge Premises t i I sto +r t nHfr
(please print)
ill Signature Title cQLiftwTda,
(over)
DOH-1555 (02/2004)