Dickinson Sr, Timothy r �-..
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NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First ' . Middle Last Sr ! Sex M
1 irn C 11 AAe-Y\ 1 cV ,nSaY, l
Date of Death I Age I if Veteran of U.S. Armed Forces,
03 105 )la1 ke , 51 i War or Dates U 1(1n_oLJ'in
Place of Death ( Hospital, Institution or
.1.4P own or Village G'en,s 1:70111 S 1 Street Address Glen& Fa1\s i-\os }-c 1 _
nner of Death Xi Natural Cause Accident Homicide Suicide Undetermined Pending
6 .1 Circumstances Investigation
W Medical Certifier Name " Title
0 .en n cev Y\ova' end% bi‘) P1.1, Sic%6 n
Address
100 car 5l-re-0A-, C(Lr c S, 10/ I 2100 i
th Certificate Filed ! District Numbe Regis ber
own or Village G r 1-e_ S Fa11 S f an\ �
['Burial 1 Date Cemetery or Crematory
[]Entombment' 03 i, J-01
Address
(]Cremation Qutevk.5`oury, ►Jy 12,56'7-
Date ' Place Removed
Removal and/or Held
and/or
Hold Address
Date I Point of
0 Transportation j Shipment
by Common Destination
Carrier j
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home 1101/4l0\or �� ND,rp,t A lw Y(Ye_ Q 11 3 C)
Address « Lc c e ze c 1'y I2 E o'-/
Name of Funeral Firm Ming Disposition or to Whom / I
t. Remains are Shipped, If Other than Above
31- Address
ir
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 3 / 2 I f 6 Registrar of Vital Statistics 'Li\)c,jem u,,k'ti ' fCJ I -
{signature) s]
District Number S C 0 f Place 6 (Q_,v\.5 V®, `` S) AP L,
r
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
N. Date of Disposition 3J/51/E Place of Disposition Fe..1 ,.' Girl%crtar,,,1,
(address)
Vi
(section) ��tat number) (grave number)
Name of Sexton or Person in Char a of Premises ate... S►v+c�t
pant)
Signature I Title (I ai- t.
(over)
DOH-1555 (02/2004)