Burke, Thomas NEW YORK STATE DEPARTMENT OF HEALTH INV
Vital Records Section Burial - Transit Permit
Name First ,.. --//- iddle La Sex
LAr
Date of Death Age If Veteran/of U.S. Armed Forces,
3/I 5 //t)Z 0/ gd War or Dates j cj S1-5_7
144. Place of Death Hospital, Institution or
"City, Town or Village rz .r. , ' Street Address 0 Q /e /1CC
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a ner of Death Natural Case �Ac ids ent ❑Homicide ❑Suicide ❑U etermined ❑Pending
Ui Circumstances Investigation
W Medical Certifier Name.
a Title
la // $A.i,
Address
Certificate Filed S Bistrict Number ��� Register Number
it, own or Village �rA� i.n ,,,,
LIBurial Date Cemetery or ematory ,-
3// �� / / v►a v CrLm-y, '"
El Entombment Address
Cremation ] ✓
Date C Place Removed
Z❑Removal and/or Held
2 and/or
I—. Address
tt
Hold
0 Date Point of
ti ❑Transportation Shipment
a by Common Destination •
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to `� --�" Registration Number
Name of Funeral Home L `AS Ms l�{ti AC ram. / H a'-C (J C>`f`f k
Address u
7 i try i,s, A v( L 7. // ).2 v ,Z--
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
's ` Address
CC
tii
U. Permission is hereby granted to dispose of the human remain rib d abom as indicated.
Date Issued Vi -/ Registrar of Vital Statistics r. -4-r,ruurul&
(signature)
District Number 1-1 S 01 Place ‹.._...C.PL., - �� %
I certyif that the remains of the decedent identified above w e disp (1/-‘'A•
d o in accordance with this permit on:
I~
W Date of Disposition 3/n J/t, Place of Disposition ant 196L.) (wmq ot,N+.
2 • (address)
I
(h
CC (section) /f (lot number) (grave number)
GName of Sexton or Person in Charge of Pre ises I t '' ,Silt
Z Tease print)
lit Signature Title reAlliire.
(over)
DOH-1555 (02/2004)