De Sanctis, Adele NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Biostatistics -Vital Records Section
Name First Middle Last Sex
............ -.. --........... :,31 :..:..............._ De. anc.tis......... Female
.........................
?� Date of Death Age If Veteran of U.S.Armed Forces,
iii<??`` War or Dates
<Z Place of Death Hospital, Institution or
AO City,Town or Village =ranville Street Address Hallmark Nursin_ Centre
)ti Cause of Death
A T; etabolic Acidosis
................
Ci Medical Certifier Name Title
> ..........._...._...............__...................._JJ.y a:d...o? s: .L....D,.::::::::::::::.................................._......_........_............
:::...........................................:.:. ......:...:.....
Address ...........................................................
im
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iiiiiiiii Death Certificate Filed District Number Register Number
City,Town or Village ` ranvi lle 5756 19
ii Date CemeteryCrematory
or
Burial Ati
.:.,:: � i ne::::VierCemetery
1. :::.::::::::::::::::.:............:.:......................
❑Cremation
Address
g..ue�n "%ur: ::,: Tew.:.:York.:::::.
Y
Z Date ii Place Removed
0' ❑ Removal and/or Held
�"
and/or Hold ::::::::::::::::::::::::::::::::::::::::::.:::::::::::::::::::::::::::::::::::::::::::;......::.::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::.:::.......::::::::.:::::::::::::::::
Address
:'l)
r3 ii Date Point of
n 0 Transportation by Shipment
Common Carrier
C Destination
Date::::::....................................................:::.:::Cemetery
El Disinterment
ry
❑ Reinterment Date Cemetery Address
•
•
Ei Permit Issued to Registration Number
Nii Name of Funeral Firm S1z1;1i van.. ....?:'I a'nazZ...: .. 'ottcx' Q1 9 z........:....;............_..
iiiini Address
Park StrQat, Gloas Falls, New.... c?rk :: ::: :..:::::::::::::.:::::.
' _ Name of Funeral Firm.Makiing Disposition or to Whom
`"'' Remains are Shipped, If Other than Above
.......................
Atit
iiiiiiiii
Address
Permission is hereby granted to dispose of the h a mains above as indicated.
/�/ r iiiiili Date Issued Au.,-;. . 11,19 8$iegistrar of Vital Statisti s /�� /��...„.. .
(signature)
ii ,, -Iv`_ 1 1e
District Number 575 6 Place �'7"a � , Nd A t': York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition T-//- r ff Place of Disposition M(addr V,.c=t,ti e Mr fc'1i y , 6)u c&AI S 6u A y) AL Y
ss)
w Nvtf.c ,14. 3-i3
N (section) (lot number) (grave number)
O
p Name of Se�x or�'erson in Charge of Premises /Po t>n1 cz y G. c $ f/e re .
w / -' i (please print) c
Signature il� ,Loy -q- /'VL i,,...c ., Title ,� ,.) V•r,
DOH-1555(9/86)p 1 of 2(formerly VS-61)