Casale, Theodora NEW YORK STATE DEPARTMENT OF HEALTH '��
Vital Records Section Burial - Transit Permit
Name ` t t Middle Last f Sex f
e- c7Ofi .-
30-f t e nl
. h l^.2—
Date of Death - Age If Veteran of U.S. Armed Force
Q f-- /-S ^ gel.? �� War or Dates
I-- Place ► a-ath ` Hospital, Institution or
ZILI City, own .r Village S c�i t-o-t #J Street Address a,( Te- Rr
a Manner of Death an Natural Cause ❑Accident D Homicide ❑Suicide ElUndetermined El Pending
W Circumstances Investigation
w Medical Certifier Name Title
d 5t!'l, ,4 tiN e 4 y I'Iv pi -0'
Address
/74 7 m tir 5r GSA 1-1-tac9 ' T jo ". i 'Z Ss
Deat ----•ficate Filed District Number Register Number
Ci , , Town .r Village i. -, —
❑Burl. Date Ce�,ery or Crematory
1r(itkOi �r
QEntombment �� !/�` !? � �'P�+,A�r"/
Address
,gCremation 0�(4.1a,�j ur�. j• ,
Date Place Rem6ved
2❑Removal and/or Held
and/or Address
H Hold
LC
O Date Point of
EL r—i
0 Li Transportation Shipment
Li by Common Destination
Mi Carrier
REIDisinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Fune Ho CA }-c- is, , / Fu,U.gr J filmy— 04,3--'/y
Address
Name of Funeral Firm Making Disposition or to Who
)4 Remains are Shipped, If Other than Above
• Address
cr.
W.
Permission is her by granted to dispose of the human re • s described abovve,,as indicated.
Date Issued __ ,,90/ Registrar of Vital Statistics ,t4, 4t cam( U62..e p
(signatu>7-'
re)))
� 9
District Number /.5�.3 Place $ci _ ft. N
1 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
z
Ili Date of Disposition I/2 0 117 Place of Disposition -ii t J 41/4 f Crh,n a-f orm-N.
2 (address)
UI
till
C (section) //(lot number) (grave number)
Ct
43 Name of Sexton or Person in Charge of Premises �hr,s r Sean eit
(pl se print)
• Signature �y y • Title l(2E nib `
(over)
DOH-1555 (02/2004)