Cucciniello, Geraldine p 1
NEW YORK STATE DEPARTMENT OF HEALTH ir 2(;)3
Vital Records Section u nal Q Transit Permit
{ Name Zst Middle Last Sex
/efaJoUv`L It ItyL Cu cr rw.•ttc• o t
Date of Death Age I If Veteran of U.S.Armed Forces,
r€< 7/3] / 6 I Wa_or Dates
F4 e of Death j .spital Institution or
FE City Town or Villa.° �]?k Ails-
I . . = A ddress 11/?M_c f//S ���/(a (
5. a:
nner of Death Natural Cause ❑Accident n l.�.1 Homicide Suicide ❑Undetermined Pending
W A Circumstances Q Investigation
1 Medical Certifier Name Title
K() t. g,e ev,S MD
Address . ,r /, ,
a3 ) ! 6 7att� CY 14- _o r ci?nc //) N y. lz8®y
_: Death Certificate Filed / District Number Regisf'er Number
( City Town or Village L7 C,, S , 0 ; �j
l.,. Burial Cemetery or remato —
❑Entombment Date ,I ]b ) 0 v_ V I -e i(V c voil Gi4 Dy
►:CremationWOAD( .. } Q (a`�2.eA,L - btA (\I) \1 i2E0 q
( Date { Place Removed
Removal 1 if and/or Held
and/or Address
tt Hold 1
0 - Date Point of
it
Ef,Q Transportation € Shipment
by Common Destination
Carrier
Li Disinterment Date Cemetery Address
'€ El Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home &AtYC tl e tx\ Hp jc 4 C2•11 J
Address _
i
1. 1.._c.:,.��=�.�c_� �. .��, Ca: � .- 1 i icy 1-2. c y
Name of Funeral Firm Making Disposition or to Whom
t Remains are Shipped, If Other than Above
Address
tu
m.
Permission is hereby granted to dispose of the human r mains de cribed abov as indi ated
Date Issued /pi,, Jr)/ 7 Registrar of Vital Statistics --t 4 /2)- :
ri (signature)
District NumberG�/ Place f
- ->. I rtify that the remains of the decedent identified above were disposed of in accordance IN' this permit on:
ce
11.1 Date of Disposition !1 I 11 Place of Disposition F,,,�,V RJ Cr,gtvri",-.
= (address)
La
= (section) /� (lot number) r (grave number)
n. Name of Sexton or Person in Charge of Premises l�:sTitr tM.i ll?,+, please print)
Signature l� Z Title Cf?'"6 2
(over)
DDH-1555 (02/2004)