Hanlon, Thomas NEW YORK STATE DEPARTMENT OF HEALTH r # /90
Vital Records Section 4.1, Burial - Transit Permit
IDDI Nam First Middle Last Sex
I omn3 3" anIQn f 7k1
Date of Death Age If Veteran of U.S. Armed Forces,
III I (f)--30 -20/`�_ (Q 7 War or Dates vie m
1- Place of Death Hospital, Instituti gaior
City, Town or Vill 4 ,( " Street Address L.--...1 S (-rasp/f Cl
Manner of Death ri Natural Cause ❑Accident 0 Homicide 0 Suicide Undetermined Pending
t Circumstances Investigation
til Medical Certifier Name Title
Address
"Death Certificate Filed rx ,,` District Number,i , , 1 Re ter Number
City, Town or Village `, •sI (p L
0 Burial Date ¢,nete r Crem tory
❑Entombment I I _Z - I J t , v e u)
Address
INCremation u ,,t\510Lk.r) f IW
Date J ace Removed
❑Removal and/or Held
and/or Address�
CO
Date Point of
it 0 Transportation Shipment
G6 by Common Destination
Carrier
Disinterment Date - . - Cemetery Address
❑Reinterment Date Cemetery Address
gii Permit Issued to Registration Number
Name of Funeral Home rr t\.e r- -i-Z,L v, J I I-Q yy t 1 y)( _ 1 1
Address
c4 C h L,L.rd- cS t La k(L L1,cie -ru Ay /2.g¢C,
« Name of Funeral Firm Making Disposition or to Whom
14 Remains are Shipped, If Other than Above
Address
In
"` Permission is h r by granted to dispose of the human rem d crib a ve as indicated.
giiii Date Issued I 1 1 I) Registrar of Vital Statistics ,,�
a } SUti; (signature)
District Numbe„air-
. Place
>.::" I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k 1U R Date of Disposition II/316 Place of Disposition J et ctof../
2 (address)
LU
ilk
CC (section) // .,(lot number) (grave number)
Name of Sexton or Person in Charge of Premises �4r° L �a �-
r please print)
Signature Title C c'�
(over)
DOH-1555 (02/2004)