Archer, Thomas - NEW YORK STATE DEPARTMENT OF HEALTH N',.
Vital Records Section Burial- ransit Permit
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to Name First Middle t ( S
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Date of Death Age j I +Veteran of U.S. Armed Forces,
lici /lo p.5� War or D I �' SSA
Place • 9-ath Hospital nstitution' r
City Town • Village . q _ 1,6- 1, Street Address AJ B3b` L,.) 7Z„� c j v(_,
Manner of Death' 3 Natural use 0 Accident 0 Homicide 0 Suicide El Undetermined n Pending tAl Circumstances Investigation
Medical Certifier Name Title
< ( 'Jn1I F6"YL #7 ErS 1913
iN Address
it —73 S;- /� 5b h_ey. .crf / Z d 5
Death Certificate Filed ? District Number Ale/
Number
Cityar Village , tc'v LC� 57sb Si
Date U Cemetery or t emator
❑Burial /1 /2-.S-140 A.)c-r LI el-.)
Address Iil /�
®'6remation v G b �G 0 06- `-..-; Q iJ
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Date i Place Removed
Z ❑Removal I and/or Held
-- and/or -- -
ti Address
- Hold
t
} Date 7uint of
NQ Transportation j Shipment
a by Common Destination
Carrier
Disinterment Date l Cemetery Address
> Reinterment Date E Cemetery Address
» Permit Issued to
it Name of Funeral Home �Qker fuller name_
Registration Number
Address 0/ ) 3�
l/ t arok/ettc . , b c twisl�ury New yo. r - l b'O
>'v': Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
r Address
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Permission is hereby granted to dispose of the human remains described above as indicated.
>`° Date Issued_ ill 2 F f/{ Registrar of Vital Statistics 04
signatur� �,t �
iiii District Number S7s'o Place (;a ,kt ki y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
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W Date of Disposition 1I/ g P 1L Place of Disposition , 4t�
1 �� �° Crw►,w4OrkPfr.
w (address)
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0 CC (section) n//(lot number), (grave number)
Name of Sexton or Person in Charge of Pr risesi r�si hJf` �E11lt�
Z (please print) 1
Signature �1 Title Ol%
(over)
DOH-1555 (9/98)