Kathan, Thomas NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
€s Name First id a Last Sex
�ho�rnns (� a ha n Ma /e
Date of Death Age If Veteran of U.S. Armed Forces,
? := I I — i -- 0-O l c 04 War or Dates id 7
Plac- • Beath �t � Hospital, Institution �r A I �� Rd
2 City, Town..r Village .. 7 Street Address
.Manner of Death❑Natural Cause El Accident El Homicide i4 Suicide ri Undetermined 0 Pending
Circumstances Investigation
Medical Certifigc Name Coitle
O Ill r t e l J 1J� r\ l� v—p r\e-r-
ill 40 MC- Ina S-Ad
d a f Is)onSPQ / )003-0
Death Certificate Filed Districf Number Register Number
`' City, Town or Village �Q Li §5 t (k'
Date Ce etery or p remator
❑Burial ( 1 —3— 20 IS Fi> V1eA' C'd't,: 4O
Addyt.p
.::?: zi Cremation t �p bl L.
J
Date
Ay
`-' Place Removed
2 2 Removal and/or Held
and/or Address
O Hold
O Date Point of
giElTransportation Shipment
G by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
0 Permit Issued to -� Registration Number
: Name of Funeral Home t ,r— ) Ofp,y1LQ I " OOa)Mi Address 1
PA— CflU.rC11 st LA,, ., 1 Zed
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above '
114 Address
re
TO
. tx .
pi Permission is hereby granted to dispose of the human main de • ed above as indicated.
in J
Date Issued I( 13 1 j Registrar of Vital Statistics c`a...U.
�t _ (signature)
. liiii District Number) , Place \ G"\ys-y\ c..k::-- --(5
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
f
Date of Disposition 1//11/c Place of Disposition 49141- .Li L its ctaarcr •
(address)
LIJ
GCC (section) , (lot numb) (grave number)
Name of Sexton or Person in Charge of Premises � - r,, tenth'
Ae (please print)
44 Signature Title CR•Pistribit
(over)
DOH-1555 (9/98)