Deloriea Jr, Thomas NEW YORK STATE DEPARTMENT OF HEALTH.
Vital Records Section # 4`17
Burial - Transit Permit
Name Firsts Middle
/ PI „k�>. Last Sex
Date of Death e, Lz `''e� .2 . /41 "(Lc__
�� �r�- Age If Veteran of U.S, Armed Forces,
H Place o n ath � War or Dates `1 `t
Cit own r Village �( Hospital, Institution or
man er Death Street Address
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0 Natural Cause ED Accident E Homicide 0 Suicide 0 Undetermined Pending
WMedical Certifier Name Circumstances Investigation
i J Title 1
`
Address (
vec r HeI4 6 _i. , e ) fir; 0 r _
( Death Certificate Filed District Number
l i City �� r Village (Ti n-, t�5 Register Number
� Date 3
I Burials/ 7(r S� Cemetery or Crematory
Address ,h e y,c .- ,-,
r� Cremation // } I r
OZ 1-1 Removal Date Place Removed
and/or and/or Held
;-- Hold Address
0 Date Point of
ai I J Transportation
Shipment
p• by Common Destination
Carrier
( Disinterment Date Cemetery Address
( Reinterment Date - •
Cemetery Address ;I
Permit Issued to , Registration Number ,
Name of Funeral Home — 1 L
Address C ;,5 ,,, -- ��n �, t��^� �"�G 7�
Name of Funeral Firm Making`Dis osition or to Whom -
t:: Remains are Shipped, If Other than Above
Address
w
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Permission Is hereby ranted to dispose of the human rQ , a,r,s scribed ov aicated.
Date Issued V�-�/ ' r— Re�istrar of Vital Statistics
(sty a re) v
District Numbers _ Place (_ / ,; /��
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
t--
' w Date of Disposition gI z111r Place of Disposition .� /+ '
to �,.i cr�o1...,
w (address)
v7
(section) �f lot numb�er
Name of Sexton or Person in Charge of Premises C� " / (\ ) (grave number)
16..414
Z. (please print)
w Signature • 4 ,,K._ Title (24 sto4pt(
vS 6
DOr1• t 555 (10/89) p. 1 of 2