Thompson, Brian 11 NEW YORK STATE DEPARTMENT OF HEAf'TW ' to
Vital Records Section Burial - Transit Permit
Name First Middle Last
Tcx Sex
����n 'rt-vl �n(�so✓1
Date of Death Age If Veteran of U.S. Armed Forces,
A0,1'-t zv ya War or Dates
Place of Death Hospital, Institution or j n
v.L.G►v) Town or Village G t-en5 �`t 1`S Street Address �)� l�s T'�'"�
Manner of Death ,/ Natural Cause ❑Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
rf Medical Certifier Name `- Title
- Address
52 Have\arid A-ve, Gikr,s ceA s N. 12-861
tf Death Certificate Filed District Number Register Number
f 5 � ( /-► 3z
,; City,Town or Village _
Date Cemetery or Crematory
❑Burial \°— 1(9 "2t�13 9,oC, UIeL) Crema r`')
Address /
::::64 Cremation Q bUr/ .
Date Place Removed
0❑Removal and/or Held
M and/or Address
g Hold
Date Paint of
[]Transportation Shipment
a by Common Destination
Carrier
..Q Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to t f Registration Number
f Name of Funeral Home f' Ord L. �er Feted Home_ 01130
`` Address 11 LQ�'
.. a-ye#e at. , bue.e�S 11v w L/orx-- Ia8ay
3v.
., Name of Funeral Firm Making Disposition or to Whom
_ Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
! Date Issued )(Di/6/t3 Registrar of Vital Statistics k,/0 ,b o k^-). -i-ce0
(signature)
District Number 5Fp/ Place E S co I l S , 7
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
g �we.tor A—
Date of Disposition 10+Ibll3 Place of Disposition g
(address)
133
CC (section) /�`(tot n tuber) (grave number)
AName of Sexton or Person in Charge of remises `'/►r,) - 3Pn,t�
(please print)
Signature z
I Title Oikniftlii
(over)
DOH-1555 (9/98)