Flynn, Thomas NEW YORK STATE DEPARTMENT OF HEALTH If I a
Vital Records Section Burial - Transit Permit
Name Fir t lest Sj
T-kaillib P4 ri AU 11-- /"!ylu
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Date of Death ,- Agen If Veteran of U.S. Arrrfed Forces,
0/- 6 7 �0 /-J / 8' War or Dates / 75'...5 — / 9.S 7
}- Place of Death Hospital, Institution or City, Town or Village 5 Cl? 1'Q '1 Street Address 6A A/df ei- f1feA d w /2&
• Manner of Death u. Natural Cause 0 Accident Homicide Suicide Undetermined ❑Pending
U Circumstances Investigation
tij Medical Certifier Name Title
Address
/L'Z, &Mak! 5i iLt=(7 G ), I.:At5 I�"1 ,i„s ttl3� i a2g{J i
Death Certificate Filed District Number Register Number
City, Town or Village •G/ - 07-- 28/S /-, 3 7 _
' >❑Burial Date etery Crremat �_
Entombment t/ /1 o 7 d'�(s ar w
Address
!gCremation r%).
Date PlacdRemoved
Removal and/or Held
R ❑ d/oldor Address
(I, Han
o Date Point of
tti
❑Transportation Shipment
O by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to _ Registration Number
Name of Fu I Ho e A fr-cL 1, .ft- - p(y Ft)be"f (4o0c{ MI Si
Address
1,131 i---ttilti-- A) / . i g—cc--7 d
iiiiil Name of Funeral Firm Making Disposition or to Whom
f Remains are Shipped, If Other than Above
• Address
CC
ill
CL
Permission is hereby granted to dispose of the human re ins described above as indicated.
Date Issued (��0 7�0/, Registrar of Vital Statistics ( �� ` `y� )
signature)
Eil: District Number t 5/.03 Place S Cit-e-ti& _A -/ jiJ r'
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
1. 0
U . Date of Disposition I Al /kr Place of Disposition ,"poi Crtw. ,
2 (address)
III
tal
I (section) 41 (lot number) (grave number)
0.
Name of Sexton or Person in harge of Premises (,�,. 1- ). f
2 (please print)
t Signature / Title crg- ilkL
(over)
DOH-1555 (02/2004)