Flewelling, Timothy NEW YORK STATE DEPARTMENT OF HEALTH '11 ��
Vital Records Section Burial - Transit Permit
Name First ---' Mid e !-) Last Sex
Date of Death U Age If Veteran of U.S. Armed Forces,
/''L €-c` 17, ;1r'(2 e-ro War or Dates
}. Place of Death Hospital. Institution or
Z City, Town o lage �f. Street Address J33 L �4. ✓z^�'_
dManner of D Natural Cause 0 Accident El Homicide a Suicide �Undetermined Pending
W Circumstances investigation
W Medical Certifier Name Title
4 �ivliMet. S 't .G� /4-J)
Address
sl' 6to.,.. 51 U ,citie4Al N i a.Z1 86
Death Certificate Filed / /�District Number Register Number
City, Town or Village (.._ c, r. `� 5- l
Date Ceme y or Crematory
I 1 Burial ,3 f! �
/ 1 K c( . 1'✓i c vices C
—� re-A-4cli. -
Address
Cremation ups. .lj. ) 0 ,
Date Place Removed
OZ n Removal and/or Held •
H
and/or Address
Hold
0 Date Point of
CL 0 —Transportation Shipment
5 by Common Destination
Carrier
�]Disinterment Date Cemetery Address
Reintermentl Date Cemetery Address
Permit Issued to _ Registration Number
Name of Funeral Home G.�s,ti+, "�„�.rc Pw 14. ' -- Qa
Address /^
7 5 €f.n ,/z"v.�/ ,,." ) ILI, 'j /a ti 2Z
Name of Funeral Firm Making Disposition or to Whom
" Remains are Shipped, If Other than Above
Address
CC
Permission is hereby granted to dispose of the human r ains scribed ..ipov s ' icated.
Date Issued 3/i 7/ ocy Registrar of Vital Statistics • 4/1/1__./
a re)
� t . .�
District Number 11 dal Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition V 15-1,/L Place of Disposition ."--)lbw cJ set.) C-iwnc4ar,"u s'
2 (address)
w
Cr (section) (lot number) (grave number)
Name of Sexton or Person in Char of Premise 4L i ,74k.
Z (please pn t) ���1
u) Signature Title etepied-orb f '.
DOH-1555 (10/89) p. 1 of 2 VS-61