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Conerty, Thomas
9 l 60 NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First , Middle Last i SeN TtroAI As Yrt>,Iv O©,Ue27}1 1 r14 I c D to of Death ! Age If Veteran of U.S. Armed Forces, a�1) aQ(5 1 71 i War or Dates No Place o Death Hospital, Institution or 2 City, Town ir Village 130\ToilJ Street Address gib No,80(T0,0 R . (�e) O Manner o Death®Natural Cause 0 Accident 0 Homicide 0 Suicide ri Undetermined ri Pending Circumstances Investigation tii �J\• Medical Certifier Name Tit e O P.J S7 b uy-(A/be� 'l,D Address v lb Ps2�cq , a!eArams 1 (J.V 110I Death Certificate Filed i District Number Register Number City, own •r Village 12o) -0,0 ! S3(p TO • 9 Date ; Cemetery or Crema ry ❑Burial Da-, 2 5j 11 NE I t 1 7d2 Address `/ (.� " IT Cremation }U�C6,� Q lire'6J sbuA y l' + /a2Fd Date `'� J Place Removed 3 C Removal and/or Held — and/or Address }-= Hold Q Date Point of CI. Q Transportation. 1 Shipment O by Common Destination Carrier • Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to _ Registration Number Name of Funeral Home __ , Rl-};t;�z2 i7 ,,U�,-, 1;, ,y4— 0i139 _ Address / if L/a- 3 1 Z:' i 0t) .oS 8Or u . / t € Name of Funeral Fm6 Making Disposition or to Whom i • Remains are Shipped, If Other than Above IAddress :: Permission is h jreb granted to dispose of the human remains de cribed bove as indicated. iiiDate Issued /GIZZ) L5 Registrar of Vital Statistics i • sigrture) d- 4E: rf' Place 1 � "' b0��O kf = District Number � V ::::: I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: WDate of Disposition /Z-20-/3 Place of Disposition A,0,U,au) C-re-tnahr y 2 (address) w cn I (section) (191 number) (grave number) • O Name of Sexton r Pers in Charge of Premises -JD,/%-c,.oi. r n-,a„c.4- (please print) W Signature �/ Title Cre-,na.7164✓ (over) DOH-1555 (9/98)