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Purner, Thomas 1 • ) # g NEW YORK STAVE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex 1 \ �p O. 0,cv r Rxr�L_� _ Date of Death Age If Veteran of U.S. Armed Forces, ©k I zl 12bj lQ g3 War or Dates y� - PI of Death t Hospital. Institution or i own or Village G)P y Ct l',S ' Street Address G FYI S Fa\1 � ► a\ Manner of Death�71 Natural Cause Accident Homicide Suicide ElUndet6rminAd Pending 4�WCircumstances Investigation Medical Certifier Name Title Q 1 C flJ V \A C\OW "\-- _Y\D Address tor) PourlL , &-nee+- C(D �a\\s N I2_301 Death Certificate Filed ,' District Number Register Per itY Town or Village G\e s F-ct \\,S JQ� 1 ❑Burial T Date Cemetery or Crematory Q� f .5 Z O1 1p ?i Yl e J ..e v.) C�c�e'mo. c1 r�j (]Entombment Address _ / Address )E3Cremation ( o \LLv C2 r C4 au2i2nSbutry / A)j \ 2 C Li Date i Place Removed rEl Removal I and/or Held and/or Address Hold Date 1 Point of ❑Transportation j Shipment d by Common ! Destination Carrier Disinterment Date I Cemetery Address Reinterment Date ID Cemetery Address Permit Issued to j Registration Number Name of Funeral Home D.\12y- Yee al\ 0'm t I 41 ac) Address 1\ 1.-o ca. e S-- . Q`* N,S\\,r 1 , N`I 1 Z ±J' Name of Funeral Firm Making Disposition or to Whom t Remains are Shipped. If Other than Above 2 Address - .- ----- —-- Cr 4 Permission is hereby granted to dispose of the human remains d crib d a ve r�I boated. Date Issued Q/ �jq/6 Registrar of Vital Statistics G �"� - (signature) District Number SGO/ Place / A- 5, 4)114 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: ,`rr Date of Disposition (/Z��Ib_ Place of Disposition ,,,t li,z... Crt.„4 or'i�..� ("address) Ut (1) {section) (lot number) C (gravy number) Name of Sexton or Person in Charge f Premises (i�"�jTO..;( -' 5t4fat (p/oboe print Signature Title _ Pt (over) DOH-1555 (02/2004)