Jones, Thomas it 1
NEW YORK STATE DEPARTMENT OF HEALTH 1 `1
Vital Records Section Burial - Transit Permit
Namejt` z. zMiddle Last Sex
Date of 6/eat / Age If Veteran of U.S. Armed Fo ces,
// / e'iJ �,'� War or Dates G'v t�1 =
p.., Place of ath Hospital, Institutio �/
Z Ci , o r Village���j�,rb(/` Street Address j470.7, ,tcj r �v�/
p. Manner of Death ..p,�aturai Cause ccident Homicide Suicide Undete mined u Pending
W Circumstances Investigation
tu V Medical Certifier Name Title
gt: -4a,-; _x_r /4---; //-/-7,r6D-7 .
iNcldress
Death cate i ed � District Number �� S Register Number
,Cit 7`ow r Village , ac/..
❑Burial Date or Cremator ,�)
['Entombment /" ' /7 a)/j .7 V4(1- r 4 AC/4/ -v7
Address �j( ,R a-�l�Z , ,,.. • ��/
remation (/� .'Gll
Date Place Removed
❑Removal and/or Held
"'
and/Holdor Address
Date Point of
0 Transportation Shipment
G by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home ��6`Aji jf i:, C,�z--1-7///
Address
Name of uneral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
cc
la
'` Permission is hereby granted to dispose of the human remains describeipove as indicated.
Date Issued `/ I ( /,6/3 Registrar of Vital Statistics 4 .� Q. .—
llll ` (signature)
District Number 6-6 s S Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2
tii Date of Disposition 1-is'-13 Place of Disposition 4;(,4Utt./ CI- loiv0-
(address)
tgi
CC (section) 4 (lot number (grave number)
0 Name of Sexton or Person in Charge of Premises G Fca l4►+(+
Z (please print)
Signature ,1►- Title MemarAit,
(over)
DOH-1555 (02/2004)