Basso, Ingrid i
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name , G
First � Y IG� Middle Last Se)
SSo
Date of Depth 2 Li Age If Veteran of U.S. Armed Forces,
) War or Dates
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Place of Death f Hospital, Institution or
Cit( own r VillageJOIArk,3k-0\-..-X) Street Address f U( (1.114- r -ct ( kSi-iill
Ma or eath I f Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
W. J"t Circumstances Investigation
Q.
ui Medical Certifier Name Title
Sin )LL CkU �Cc)COS
Addres ,q CO Un}N ' y I Z2- C(dv�svl l� Ni.'? ( �7$
Death Certificate Filed `District Number Register Number
Ci ,COW) or Village sjc�hnSOw� 7.5�
Buria� Date Cemete or Crematory
❑Entombment Addresy6\ \2'1 ► v`Cw ( -a 1
['Cremation l�►l�- eri\SbO'CLI r N�
Date Place Removed
ZnIRemoval and/or Held
2 and/or Address
�
Hold
Date Point of
EL Transportation Shipment
Li by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
iiiiiiPermit Issued to Registration Number
Name of Funeral Home
iiE Address
Name of Funeral Firm Making Disposition or to Whom
14 Remains are Shipped, If Other than Above
2 Address
1U _'`�t
T
P." Permission is hereby granted to dispose of the human rem ' scribed abpye as indicated.
�
Date Issued �,\\�� Registrar of Vital Statistics /{`i
(signature)
lig District Number \--)S14 Place ��..,),(\ $' i,\ fVl r)
4, I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
z
111 Date of Disposition Place of Disposition
(address)
tli
fa
CC (section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises
(please print)
Signature Title
(over)
DOH-1555 (02/2004)