Clifford Jr, Thomas c ‘
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial ® Transit Permit
Name First Middle Last I Seat
_`__ ,I }�r/ S ,"12►8-�C.-I S tn r�-r=0,1-40 .J .�, /fez,tc
Date of Death / Age I If Veteran of U.S. Armed Forc '7
`i ! Z® 8 (o .Y.-� I Dates /aV i'c
P P . e of Death Hospital, I stitution or
own or Village L -,s /`--vtj reet Address Li(,V'../S - S
Ci v ..nner of Death qNatural Cause 0 Accident ❑Homicide ❑Suicide Undetermined El Pending
LLI Circumstances Investigation
j Medical Certifier Name Title
P /)01i c_ rE0-.).-//y0,)
Address 3 76? /(/29)-.1 a ,, L.)4ru/L6,7--Li 3 1-414 l Uy. (Z Fe-.��
ne th Certificate Filed f District Number Register N(� ber
r ` g
<-< Ci i own or Village (7t,r,J.S /` S ( 0\ l 1 S. .
Burial Date Cemetery orrematory,
9 /2 co /(., [i,..) c-,.7.- ii 1 61..\)
°Entombment Address ,(�
Cremation c U B/C b� /J G..._ f�-1�1 v c-c.'.is 6 tin--el /"
Date Place Removed / 1
X — Removal and/or Held
—and/or Hold Address
V)
10 Date Point of
it fs`3❑
Transportation Shipment
5 by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date I Cemetery Address
Permit Issued to �"� Registration Number
Name of Funeral Home L&'.� ( c ;l�.t\ �-'r0�� I C t 1 �,0
Address
1\ Le ` I vCL\1��:_s; -I , t" iZ-Cy
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
rc
LU
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 9 j2 0 1 )4, Registrar of Vital Statistics U\,l
(signature)
District Number 5 6 0 � Place 6 Gwv S � l 1 S/ A) Ul
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
lig 'I
Date of Disposition 1126IIIL Place of Disposition gmVfhW C , riA.
(address)
III
f a
i (section) ji (lot number) - (grave number)
Ci Name of Sexton or Person in Charge f Premises a(`,f 3 e441ir
( ease print)
1g Si nature Title it MA*
g
(over)
DOH-1555 (02/2004)