Bellos, Anne NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Midcite Last Sex
AN � RAt2_E.Ka g3E,LLOS Erk.\RUE,
Date of Death Age If Veteran of U.S. Armed Forces,
eE,R :-2 IA) 3-00(o War or Dates 1y J A
{- Place of Death Hospital, Institution or
CitIIIy,T-ev n-ei-Vill ge- Street Address CI-LEAS .'(\LIB Bose 1�CY�L...
a W Manner of Death Natural Cause ❑Accident ❑Homicide El Suicide El Undetermined ❑Pending
Circumstances Investigation
la Medical Certifier Name Title
P. REC)ECC �`\ ETZE(Z 1\
Address
100 VARV.5 CLEFS -AL(_S Off.)'?\ 'ftL) G-LEK;S 'FP\ULS;'Y\Uy 11%"0 1
Death Certificate Filed District Number Q Register Number
City, a_LCaS . -AI.I,S S60/ 59,3.
❑Burial Date Crematory
❑Entombment OCT, )-5 ) -4C0(c 1 NE 1 L.D CR_Erc\P-7o \�v\—)
Address
remation a �t�A\LEs �_,D,) (7u EE.,tJSQ(A )`- \ DA 0 4
Date Place Remove
{9 ❑Removal and/or Held
and/or Address
C. Hold
t3
C= Date Point of
IL
❑Transportation Shipment
E: by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home
\(A t,—;ct_P\L. �\ (ykE)1 r( 01'-1 lO
Address
gi Name of Funeral Firm Making Disposit?on or to Whom 6
Remains are Shipped, If Other than Above
', Address
ILI
IX
s` Permission is hereby granted to dispose of the human remains desc ibed bo as i d.
Date Issued r,,c , °S ,Registrar of Vital Statistics
(signature)
District Number 6."(eo1 Place �t,E L(._ .) Cc� {`` .
' I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k �
ILI Date of Disposition kJ/2 g/bl Place of Disposition PintvLtJ Ctin,4{-o(1W,N
(address)
ilk
W (section) (lot number) (grave number)
a Name of Sexton or Per n in Ch rge of Premises ��r'•s +v,+t
Z (please print)
Signature Title C e-+oe
(over)
DOH-1555 (02/2004)