Thompson, Robert 5 of
NEW YORK STATE DEPARTMENT OF HEALTH 0 . 1
Vital Records Section i Burial - Transit Permit
Name First beg i PA v�iddle 7Th,4PvO s� Sex
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Date of Death C.V A If Veteran of U.S. Armed Forces, J"�
4(J6 a,?.c2Q li 6S War or Dates (Ye-3) A/O ln/¢C)
Place of Death Hospital, Institution or
City ow1:1r-V+{iage/i//1/2/z/EIJ AVAJ Street Addres /A - SA A 4 AM c LA ice .
0 Manner of Death..Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ri❑Pending
kt Circumstances Investigation
W Medical Certifier Name Title
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Address
Anil - ,t1edicAc. C'eivre4-12i g6- .,AiZANAC 1.a4/ it- AVY /0-(7`63
Death Certific. - Filed -70LAJv„)0r Ablill+efJ ad.v District Number j,/` Register Number
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❑Burial Date Cemetery or Crematory
❑Entombment Address 0
}Cremation / G?UAi a - A.4 t%�..-S 6 1"\ ,14 /Z-C6C)ci
Date Place Removed
Removal and/or Held
0 1-1 and/or
ri,,. Address
to
Hold
O Date Point of
fiti❑Transportation Shipment
5 by Common Destination
Carrier
Q Disinterment Date Cemetery Address
•
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral HomeJ e .�AjZ/A-., //V C , 0/0 75
Address ���) -AiC4,OA( Ati Zi(ke_ AiGcld /Uy /eqvC.
Name of Funeral Firm Making Disposition or to Whom
} Remains are Shipped, If Other than Above
2 Address
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a`...... Permission is hereby granted to dispose of the human remains described abe tas indicated.
Date IssuedOZ-Z6*-040i3 Registrar of Vital Statistics
( nature)
District Number/ 3 Place Village of Saranac Lake \
:: I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k
W Date of Disposition 0/g 13 Place of Disposition A`✓tt. i/- r.A/ Ore."40,1S-7,01
2 (address)
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Ul
Ir (section) (lot number) (grave number)
Name of Sexton • Per n i rge of Premises .�) R tJ 1",d
Z (please print)
Signature 1 !Ono'
Title 4e-,A'"A4 As i
(over)
DOH-1555 (02/2004)