Loading...
Lee, Thomas ! N. NEW YORK STATE DEPARTMENT OF HEALTH # st g `Vital Records Section Burial - Transit Permit Name First i'% 2) fiddle Las Ser Date of Death // • Age If Veteran of U.S. Armed Forces, 9/02-3(//3 G War or Dates gevz.2 /9 7 -/f,/ 1,. Place of Death Hospital, Institt.l#'lon or City, Town or Village Cla 1, u Street Address /S/✓ l:4_ 2L . Manner of Death�b f71 Natural Cause ElAcci ent ❑Homicide ❑Suicide El Undetermined ❑Pending tijCircumstances Investigation al Medical Certifier Name Aa%'�c�>�- ! Title ni) Address /a 2. 44 , (.E.6— , V , Death Certificate Filed Dict�N�u-mber R titer Number City, Town or Village Q ` >Lys`� �©1,`� ['Burial Date C etery or Crematoy ❑Entombment ��'� /(3 .�r-C /,Gu.0 ,C'i-c�yra-Gt �-�- Address ptremation `1 Date Place Removed t ❑Removal and/or Held and/or Address CA Hold 0 Date Point of fh❑Transportation Shipment O by Common Destination Carrier ❑Disinterment Date Cemetery Address El Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home , 1.....",f,‘,..„/ e'/`f44---, Address a exL %U Q,,/ >Z4 , 7,?6 Name of Funeral Firm Making Disposition or to Whom / ,/ } Remains are Shipped, If Other than Above Address CC LU ,` Permission is hereby granted to dispose of the human remains described above}as indicated. Date Issued 9i,c _t IBC)) Registrar of Vital Statistics +<)C-v\ii-- e' , 06 f) t (signature) District Number( 1 Place I certify that the remains of the decedent identified above were disposed of in accor ance ith this permit on: list Date of Disposition Q r 4 j13 Place of Disposition 4,0 a•J Cn,..c rr,._ ► (address) ill to cc (section) lot number) (grave number) O Name of Sexton or Perso in Charge of P mises .i s — r (plea print) Signature Title memPtTdi_ (over) DOH-1555 (02/2004)