Thomas, James NEW YORK STATE DEPARTMENT OF HEALTH
LiZ?
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
)42,---p-L.G0 rn c,.c.,,ketz.e.- %h 071 m
Date of Death Age If Veteran of U.S. Armed Forces,
0 1 Co War or Dates NO
-� Place fo Death a c � S n1 0--sz__,-_ . . Hospital, Institution or b ,A .� a.c...R,_
Z City,r;Tow'n)or Village Street Address Y S r- -dr.
114
0 Manner of Death®Natural Cause 0 Accident 0 Homicide 0 Suicide riUndetermined u Pending
US Circumstances Investigation
tu Medical Certifier Name Title
Address
/0 D Poi,.-k-- ,-C -11Le- 'T,Li4J- 1 a d? O
Death Certificate Filed District Number Register Number
City, 64 or Village f`'N- °-`-'z-w----
OBurial ' Date - Cemetery or Crematory
Entombment Address
iiig InCremation a. \. (' .=-x--A--- . . r\-'� 13. ) L ..f
Date Place Removed
Z❑Removal and/or Held
and/or Address
H Hold
fa
C? Date Point of
Q Transportation Shipment
. by Common Destination
Carrier
Q Disinterment Date Cemry Address
j Q Reinterment Date Cemetery Address
lilia Permit Issued to Registration Number
1 L3 Name of Funeral Home " 1'�--2,., (7.- , 1-i-,-,-„-L._ Q / U '7 .
Address
[3 to 0-N. a,+—, ..6- ,, oz t Pr-,..o f- -L.2, rv--A3 /c-d'0-3
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
#r
ILI
' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 1/3)/y Registrar of Vital Statistics4e..-e---a4/4„.. 41 `&14--�
(signature)
District Number t1/5(p Z Place % GJ n cr ) /J j Q Li Q 4,....
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
ILI Date of Disposition 1 f 5j/ly Place of Disposition &tau, (.r t (t+A-,
(address)
III
ta
ilk (section) (lot number) (grave number)
CI Name of Sexton or Perso in Charge of Premises 5f�;fi ase print)
(P P )
iLl Si nature Z4s,' Title C�(?� Mint
g /
(over)
DOH-1555 (02/2004)