Brooks, Thomas 3IHNEW YORK STATE DEPARTMENT OF HI L
Vital Records Secti•n -N Burial - Transit Permit
Name First Middle Last Sex
as E 6 rucoks N.Q le_
Date of Death Age If Veteran of U.S. Armed Forces,
5 --a^7-a-C I3 �-1 War or Dates I Of Le 7` (C 7D
f Place of Death i Hospital, Institution or
2 City.Cfow■�or Village I� Street Address 5'18 s"I n/ 0,(`� k� Rol
Manner of Death El Natural Cause 0 Accident El Homicide Ei Suicide Undetermined 0 Pending
Circumstances Investigation
Medical Certifier A Name Title
CI `]\Tol Jicon M �-
Ads
::..!'• eXrInIK N y_
Death Certificate Filed T-District Number Register umber
City, ow r Village -I 1ftd Ie � �S-B
Date C etery or Crematory
E]Burial --ale
05---a g13 tom' we It
Address 1
�,Cremationi ytip__ ►c N\/
Date J Place Removed
02❑Removal ' ^ and/or Held
- and/or Address
—iiHold
Q Date Point of
Q Transportation Shipment
0 by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home3.1 Tq_7.t _YISL 47L( p yyt,te Inc _ O( /
ica . o
Address + n n,/
i„•:,:,, Name of Funeral Firm Making Disposition or to Whom
" Remains are Shipped. If Other than Above
Addressvo
Ill
Permission is hereby granted to dispose of the human re ins described
above a indicated.
Date Issued 5-7d b7•�/3 Registrar of Vital-Statistics �� Le (�
(signature)
District Number'V5 5' Place i - -t_ 492 yVa.e
igee/
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
1!- , 1
WDate of Disposition S 1 Ft(13 Place of Disposition 'G,s(�itu, CrrA„cto,
a (address)
tti
C (section) (lot umber) (grave number)
GName of Sexton or Person in Charge of Premises AA Maly.
(please print)
W Signature it . 6-- Title CeireMIVOIC
1
DOH-1555 (10/89) p. 1 of 2 VS-61