Warner, Thomas NEW YORK STATE DEPARTMENT OF HEALTH I-0
Vital Records Section iv Burial - Transit Permit
Name First Middle Last S x
�o Li.) (‘-)a•••••___ • 61-if-
Date of Deat Age If Veteran of U.S. Armed Forcp s,
6 �23 / I X top War or Dates ,.il Ye'
I*. Place of Death eospital, rltitution
Town or Village L4 F ,i, 1 Street Address (Le,.) 1i-itis
a f anner of Death Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined El❑Pending
iti Circumstances Investigation
ut Medical Certifier Name /� Title
f e�L.- B i Mri /t1
Address
1M AJ (-Ni ff vw\s-.s.1 d ug.-. .AA/
th Certificate Filed District Number Register Number
City own or Village G14o",,rs F811_,J S'd _ 3 2
❑Burial Date Cemetery oremator ,Q
❑Entombment 6,1 �` �, (� l ' " ` 0,-3
Address •
Cremation C .0-N_ / 0 ,,.)33Ut7tAi /17
• Date •Place Removed
❑Removal and/or Held
and/or
Address
Hold
In .
0 Date Point of
EL Transportation Shipment
�. t/3
0 by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home r c. Pri 0/ A3 D
Address
II /7 1 2-5-0 y
qi Name of Funeral Firm Maki Disposition or to Whom //
14 Remains are Shipped, If O er than Above
Address .
ILI
fl"` Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued j l'ZN I (rj- Registrar of Vital Statistics ti•Jr� �,Y
(sign re)
District Number 5 G n i Place 6 u.,,,„ s i �S /
certify that the remains of the decedent identified above were,disposed'of in accordance with this permit on:
k �
II Date of Disposition (o_a�-/S Place of Disposition T,`ne v;.)<.,) Cr-en,, of''04,1
12 (address)
ta
CC ( n) i (lot number) (grave number)
ilk Name of Sexton or P rson in Ch. ge of Premises it Ma 4 ve e/'
`f-� /f li / (please print)
Signature �! Title Cf-£n?S dr7 PO
(over)
DOH-1555 (02/2004)